Assign a Different Surname Application Form

• Published date: 07 May 2021
• Issuer: Department of Social Protection

Version 1.0 22nd April 2020

APPLICATION TO ASSIGN A DIFFERENT SURNAME

I/We wish to record the surname: _______________________________

in relation to the birth registration of __________________ born on _________.

Birth Reg ID: ________________________________

The reason for the requested surname is _______________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

I attach the following evidence in support of the application

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

Signed : _______________________________ PARENT

Date : ______________________

Signed : _______________________________ PARENT

Date : ______________________

Contact Details : Address ____________________________________________

__________________________________________________________________

Phone : __________________ Email : ___________________________________

*If both of the parents have not signed the application form, evidence must be provided by

the applicant(s) to show that the other parent did not give consent because they were

uncontactable.

I am satisfied that the circumstances warrant the surname being assigned

Signed :_________________________________ Date : _______________

Superintendent Registrar / An tArd-Chláraitheoir

APPLICANTS SIGNATURE(S) * TICK IF APPLICABLE

OFFICE USE ONLY

The Civil Registration Service administers Ireland's system of civil registration. A person is required by law to provide personal data to

register a life event (birth, stillbirth, death or marriage) and personal data may be exchanged with other public bodies and public

authorities where provided by law. A person is required to provide personal data when applying for certificates of vital events and for

searches of indexes to the civil registers. The data policy of the Civil Registration Service is available at

www.gov.ie/dsp/privacystatement or in hard copy on request.