Please fill out and then print the following form. Then, make a copy
of your Driver's License or your state issued identification card (if
available) and fax both to:
(281) 930-1595
The box that says V-Code means the last three numbers on the back of
your Visa/Mastercard in the signature box.
Please type in all caps below.
Fees: State Fee $25.00-$60.00 plus our fee of $45.00 for regular processing
Emergency
Birth Certificate Processing (additional fee of $25.00)
CALIFORNIA
ORDERS NOTE THE IMPORTANT INFORMATION BELOW:
Please
be aware that California birth certificates are taking a long time
to process. On 12-1-06 the Department of Vital Records stopped accepting
walk in birth certificate requests from the general public because
of financial problems. We are able to submit requests to their
office and we are given special treatment, our average process times
are 6-7 (4-5 Emergency) business days. Until further notice these
process times will be in effect.
4-6 Day California walkthrough service, ALL fees included $136.00
If you selected 'yes,' click HERE
to download the additional forms for California.
CERTIFIED
BIRTH CERTIFICATE
Credit Card Number:
Expires:
Choose one:
Name on Credit Card:
V-Code (required)
Credit Card Billing Address:
City
State
Zip
Social Securtiy Number:
Certificate Holder's Name at Birth (or adopted name):
Father's Name: Mother's Full
Maiden Name:
Birth Date:
State of Birth
County of Birth:
City of Birth:
Social Securtiy Number:
Were parent's married at time of birth?
Adopted or Legal
Name Change If adopted use
adopted name and adopted parents' names, Pre-adopted certificates are
unavailable Hospital:
Sex:
Number of Copies:
Ship Method:
Express Courier Date of
Departure:
Ship-To Name
Ship-To Address
(no P.O. Boxes)
City:
State:
Zip:
Daytime Telephone:
(
) -
-
- Extension
Alternative Telephone Number:(
) -
-
Email:
Signature:__________________________________________________
Date:
I authorize
www.unitedstatesbirthcertificate.com and its affiliates to obtain my
birth certificate for me.
I understand that www.unitedstatesbirthcertificate.com is not responsible
for any service performed by any overnight courier service.
All Sales Final
** By signing this form I agree that there are no refunds by www.unitedstatesbirthcertificate.com.
Please fax a copy of your driver's license (if available--for minors
please fax a copy of the parents' license)
Please insert any special instructions below (if your shipping address
is a business address, please insert this
address below).
If
you will not be at your shipping address to sign for the overnight courier
package when it arrives
then you will need to leave a signed letter on your door requesting
that the package be left wherever
you specify