HD1107F REV 01/04






    






      





































Pennsylvania Department of Health - Division of Vital 
      Records















Long Form Certified Birth Certificate Request










Records available from 1906 to the 
present
























  


    




    






















By my signature below, I state 
I am the person whom I represent myself to be herein, and I affirm the 
information within this form is complete and accurate and made subject to the 
penalties of 18 Pa.C.S. §4904 relating to unsworn falsification to authorities. 
In addition, I acknowledge that misstating my identity or assuming the identity 
of another person may subject me to misdemeanor or felony criminal penalties for 
identity theft pursuant to 18 Pa.C.S. §4120 or other sections of the 
Pennsylvania Crimes Code. 

































  






    





Signature of person making request:







      





































(Required)











































    





______________________________________________________________________







      





































(If under 18, parent must 
      sign)



































































PRINT or TYPE your name & 
credit card billing address (Certificate will only be mailed to your credit card billing address): 



















  






    





Name:






    





 






    





Address:






    





 












  






    





City:






    





 State:   Zip: 






    





Daytime phone:






    





































                












                        







                                






                                        





Relationship to person named on certificate: 
                                                   Reason for request: 






                                






                        






PHOTO ID REQUIRED: THE INDIVIDUAL REQUESTING THE RECORD MUST FAX A LEGIBLE COPY OF HIS OR HER GOVERNMENT ISSUED PHOTO ID ALONG WITH THIS COMPLETED APPLICATION. (Examples of acceptable ID: Valid state-issued driver's license or non-driver photo ID with requestor's current address, valid passport, etc.) 







                        







                                






                                        





Intended Use of Certified Copy: 






                                






                        












                







                PRINT or TYPE below with regard to person named on requested 
                        certificate:     Number of copies: 



















  






    





Name at Birth: 






    





Sex: Male Female












  






  


































    





If name has changed since birth due to adoption, court order, or 
      any reason other than marriage, please list changed name here: 
       






    





Date of Birth: 







      





































                 (Month/Day/Year)

















































  






    





Place of Birth: 







      





































(County and City/Boro/Township in Pennsylvania)











































    





  Age Now:  












  






    





Full Maiden Name of Mother:  












  






    





Full Name of Father:  























In addition to the cost 
of $10.00** per certified copy, there is a $7.00 service fee to utilize a credit 
card as method of payment. Complete this application and fax with legible 
copy of ID












                                







                                        






                                                





Select Carrier:







                                                        (Additional fee charged to credit card for express delivery)






                                                





First Class Mail






                                                





FedEx






                                                





UPS






                                                





Express Mail






                                        






                                
































                                        






                                                






                                                





Type of Credit Card:    
                                                        Master Card    
                                                        Discover    
                                                        Visa    American 
                                                        Express






                                        


















                                        






                                                





Credit Card #
                                                           CVC:
                                                           Expiration Date:
                                                






                                        


















Card Verification Code (CVC): Three-digit code is printed on the signature panel on the back of Visa and MasterCard debit/credit cards. Four-digit non-embossed code is located on the front of American Express cards.



















** The $10.00 fee may 
not be required for birth records of Armed Forces members and their 
dependents. If selecting an express carrier, the $7.00 service fee will be 
charged in addition to the express carrier charges. Please complete the 
following information: 



















  






    





Armed Forces Member?s Name:  






    





Service Number:  












  






    





Relationship to Armed Forces Member:  






    





Rank & Branch of Service: