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Please complete, sign and mail with check or
money order. Include required ID (see instructions).
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Name (as listed on birth
certificate):
(First Middle
Last)
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Date of Birth:
(mm/dd/yyyy) |
Town, city or village where birth
occurred:
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Name of hospital where birth
occurred: (If known)
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Maiden Name of Mother (as listed on
birth certificate):
(First
Middle Maiden Last)
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Name of Father (as listed on birth
certificate): (First
Middle Last)
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Purpose for which
Record is Required:
(Check one)[
] Passport
[ ] Employment
[ ] Driver license
[ ] Veteran's benefits
[ ] Social Security
[ ] Working papers
[ ] Marriage license
[ ] Court proceeding
[ ] Retirement
[ ] School entrance
[ ] Welfare assistance
[ ] Entrance into
Armed Forces
[ ]
Other (specify)_________________________________________
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What is your relationship to person
whose record is required? (If self, state "SELF")
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If attorney, give name and
relationship of your client to person whose record is required:
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This office requires written authorization of
the person/parents whose record is required |
Signature of Applicant:
Date signed:
(mm/dd/yyyy)
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Applicant's Telephone No.:
(
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If delivery is to a P.O. Box or third party,
you must submit with this application a statement signed by the
applicant and a copy of the applicant's driver license.
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Regular Handling [ ]
$10.00 x
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Name & Address of Applicant
Name:
Street:
City:
State & Zip:
Please remember to submit with a form of
ID. Drivers License etc.
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Delivery
Address
Name:
Street:
City:
State & Zip:
There is a $10.00 fee for each copy.
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