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(Last 3 digits on the back of your credit card for Visa/Mast/Dis.or 4 on front of Amex) CVC-Code
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| Credit Card Number: Expires | |||||
| Certificate Holders Name at Birth: (If adopted use adopted name and adopted parents names .) |
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| (First)(Middle)(Last) |
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| Fathers Name: |
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| (First)(Middle)( Last) |
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| (First) (Middle)( Maiden Last Name) |
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| Certificate Holders Birth Date(MM/DD/YYYY) State of Birth | |||||
| County or Borough of Birth
City of Birth
*Adopted or Legal Name Change excluding Marriage Sex: of Certificate Holder Relathionship to certificate holder Is Certificate Holder Still Living ? Person making this request Birth Date(MM/DD/YYYY) Person making this request complete Social Security # Number of Copies |
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| Hospital: Reason for request | |||||
| Ship Method: UPS Date of departure(If Needed for Travel):
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| Ship to Name:
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| Ship to Address:***
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| City
State:
: Zip:
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| Daytime Telephone # (
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E-xtension:
Alternate Telephone # ( ) - - E-Mail |
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| Applicant's Signature:_____________________________ Date
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I authorize USBirthcertificate.Net to obtain my birth certificate for me. By signing the form above I agree that I have read the order form completly and if the information that you have provided is incorrect, insufficient, or the government agency has no record of the birth that there are no refunds of USBirthcertificate.net's services fees for any reason . I understand that USBirthcertificate.net is a private expediting service and I am hiring them to expedite my birth certificate order. (We don't create, change or ammend birth records. We only retrieve existing records.) We cannot obtain birth certificates for Connecticut , Iowa , Puerto Rico or New Mexico. ALL SALES ARE FINAL. ADDITIONAL OPTIONS: Please charge me "total service fee $180" for our regular passport and birth certificate processing fee To process or for questions see below or visit our passport section for additional instructions on passport processing.(Please note these fees don't include the government fee for processing a passport.) Emergency Processing (Regular fee plus additional fee of $25.00) Please note emergency processing doesn't change the stated State processing times it just puts your job in front of any regular job that came in before your job.
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