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APPLICATION FOR FLORIDA BIRTH RECORD Florida …

APPLICATION FOR FLORIDA BIRTH RECORD FLORIDA Department of Health in Broward County Vital Statistics Department 780 SW 24 Street, Ft. Lauderdale, FL 33315-2643 (954)-467-4413 Requirement for ordering: If applicant is self, parent, guardian, or legal representative, then the applicant must complete this APPLICATION and provide photo identification. If applicant is not one of the above, the Affidavit to Release A BIRTH certificate must be completed by an authorized person and submitted in addition to this APPLICATION form, along with photo identification. Acceptable forms of identification are the following: Driver s License, State Identification Card, Passport, and/or Military Identification Card.

If not one of the above you will need to complete the form and have a notarized Affidavit to Release A Birth Certificate (DH Form 1958 2/03) submitted with your application for the birth record along with your photo identification. RELATIONSHIP TO REGISTRANT: A person ordering his or her own certificate should enter "SELF" in this space.

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