APPLICATION FOR A CERTIFIED COPY OF A BIRTH …

1 APPLICATION FOR A CERTIFIED COPY OF A BIRTH CERTIFICATENEW JERSEY VITAL RECORDSC ertificate information :The authorized vendor for NJ Vital RecordsFull Name of Child at Time of BIRTH (Certificate Holder)first middle lastsuffixFather's Full Name (if recorded on the record)first middle last suffixMother's Full Maiden Namefirst middle last (maiden)Exact Date of BIRTH (MM/DD/YYYY)Name of Hospital (Optional)Gender Male FemalePlace of BIRTH (City, Town or Township)

2 County of BirthIf Child's Name Was Changed, Indicate New Name and How It Was ChangedApplicant/Shipping information :Name of Applicantfirst middle last suffixStreet Address (must match address on identification)Relationship to PersonNamed on Requested Record(Proof required if ordering a certifiedcopy):City State Zip CodeDaytime Telephone NumberE-mail AddressSignature of ApplicantDate of ApplicationWhy is the record being requested? Passport Driver's License School / Sports Social Security Card Social Security Disability Other Social Sec.

3 Benefits Veterans Benefits Medicare Welfare Genealogy Other: _____Pricing: Identification Requirements: Certificate Fees:QuantityPriceTotal AmountCertificate (1st copy)1$ $ Copies$ $ Delivery (check one):Delivery Method / Processing TimePrice Total AmountNext Day (15 - 18 business days)$ $ Day (19 - 22 business days)$ $ Mail (30 - 34 business days)No Charge$ *VitalChek Processing Fee:$ $ $ *The VitalChek processing fee isapplied per order, not per certificatecopy, as long as the certificates arebeing shipped to the same address.

4 All applications must include one of the following: Valid Photo Driver's License Photo Non-Driver's License-Or two alternate forms of identification, such as: Non-photo State Issued Driver's License Vehicle Registration Insurance Card Voter Registration Passport Green Card County ID School ID 2 Utility Bills (within the last 90 days)When making a copy of your photo ID, pleaseenlarge and lighten to improve information :Payment Method (check one): Check Money Order Visa MasterCard American Express DiscoverCredit Card NumberCredit Card Expiration DateCardholder's SignatureDateImportant Note: The cardholder's billing address MUST match the shipping address provided above.

5 Applications with credit cardpayment information and proper identification documents may be faxed to: NOT MAIL CASH - Make check or money order payable to VITALCHEK, PO Box 308, Brentwood, TN 37024-030814115 FOR VITALCHECK USE ONLYOrd # _____