CÃÂºram V7 User Interface

Reference Number

Last Name

First Name

Date Of Birth

Gender

Address Line 1

City

Birth Last Name

Mother's Birth Name

	Alt.Reg	Action	Reference Number	First Name	Last Name	Address Line 1	City	Date Of Birth
[mapped-image]	[mapped-image]	Select	[Value]	[First Forename]	[Surname]	[Value]	[Value]	[Date]