Birth Certificate Order Form
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Complete this application, then fax to Express Birth Records toll-free at 877-684-5852 Customer Service: 888-803-1118.
Required fields are noted with (R) Please print with dark ink!
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Certificate Holder's Name:(R) First___________________Middle___________________Last__________________________
(Name on Certificate when born) ( If no middle name, or unknown, then leave blank.)
Gender:(R) Male ___ Female___ Adopted?:(R) Yes ___ No ___ Still Living?:(R) Yes __ No ___
Birth Date:(R) Month _______ Day _____ Year ________ Hospital: ______________________________
Birth City:(R) _________________________Birth County:(R) _______________________ Birth State:(R) ____________
Father's Name:(R) First____________________ Middle _____________________ Last ___________________________
Mother' Maiden Name:(R) First ________________ Middle ____________________ Last ___________________________
( Last Name before marriage)
Your Relationship to Certificate Holder:(R) _____________________________ (self, mother, father, etc.)
Number of copies:(R) ____________ Reason For Request:(R) __________________________________
(Travel, Driver's License, etc.)
Requestor's DOB:(R) Month ______ Day _____ Year ______
Last 4 digits of Requestor's Social Security #:(R) _________________
**** (Records coming from Kansas and Michigan require the full social security number) ****
*** The following States ship Express Courier ONLY : AZ, NJ ,NC
***Method of Shipping: (R) Regular Mail ___ Federal Express___ (please check a shipping method)
"Ship to" Name:(R) (Person ordering Certificate) __________________________________________________
"Ship to" Address:(R) (street, apt. #) _________________________________________________
City:(R) ________________________________ State:(R) ________________Zip Code:(R) ______________
Contact Number:(R) ( ) __________ - _________________ ( in case we need to reach you )
Payment Method:(R) Visa___ Mastercard___ American Express___ Discover___
Credit Card Number:(R) ___________________________________ Expiration Date:(R) ________________
Card Verification Code (usually last 3 or 4 numbers on back of credit card): _______
Name on Card (Card Holder):(R) _________________________________________
Credit Card Billing Address :(R) (street, apt. #) _________________________________________________
City:(R) ________________________________ State:(R) ________________Zip Code:(R) ______________
email address:______________________________
Applicant's Signature:(R) ________________________________________ Date:(R) ____/____/_____