Isc-Vsr-Vs031 Form - Application For A Birth Certificate
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1
2APPLICATION FOR A BIRTH CERTIFICATE
1301 - 1st Avenue
Vital Statistics
Regina, Saskatchewan, S4R 8H2
Telephone: 306-798-0641
Toll Free: 1-866-275-4721
Fax: 306-787-2288
THE FOLLOWING MUST BE COMPLETED WITH INFORMATION
PERTAINING TO THE REQUIRED BIRTH CERTIFICATE
Sex Quantity
Type
SURNAME
Given Name(s)
(MAIDEN name if certificate is for a Married Woman)
Short Form
($25 each)
Date of Birth
Place of Birth
Long Form
Month
Day
Year
($25 each)
, SASKATCHEWAN
Certified Photocopy
BIRTH SURNAME of Father
Given Name(s)
of Registration
($50 each)
Genealogical
BIRTH SURNAME of Mother
Given Name(s)
Photocopy
($50 each)
For Office Use Only
THE FOLLOWING MUST BE COMPLETED BY THE PERSON REQUESTING THE BIRTH CERTIFICATE
Name (please print)
Address (Number/Street/Apt. Number/Rural Route/Box Number)
Community, Province/State, Country
Postal/Zip Code
Home Phone Number
Work Phone Number
Reason Why Certificate(s) is (are) required
Relationship to person named on certificate(s)
Certificates to be:
Same Day Service
Mailed
Picked Up
Office use only:
Date picked up:
THE FOLLOWING PERSONAL IDENTIFICATION
Document:
Number:
HAS BEEN PROVIDED
Document:
Number:
(see reverse for types of ID required)
Signature of Applicant
X
Date Signed
PAYMENT METHOD (see reverse for applicable fees)
Cheque
Money Order
Visa
MasterCard
Credit Card#
Name on credit card
Expiry date
Amount Enclosed/Authorized $
Signature of cardholder X
Vital Statistics Registry
ISC-VSR-VS031 - 2009 01 06
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