New Jersey Application For A Certified Copy Of A Birth Certificate

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APPLICATION FOR A CERTIFIED COPY OF A BIRTH CERTIFICATE
14115
NEW JERSEY VITAL RECORDS
FOR VITALCHECK USE ONLY
The authorized vendor for NJ Vital Records
Ord # ___________________
Certificate Information:
Full Name of Child at Time of Birth (Certificate Holder)
middle
last
first
suffix
Father's Full Name (if recorded on the record)
first
middle
last
suffix
Mother's Full Maiden Name
first
middle
last (maiden)
Exact Date of Birth (MM/DD/YYYY)
Name of Hospital (Optional)
Gender
Male
Female
Place of Birth (City, Town or Township)
County of Birth
If Child's Name Was Changed, Indicate New Name and How It Was Changed
Applicant/Shipping Information:
Name of Applicant
Relationship to Person
Why is the record being requested?
first
middle
last
suffix
Named on Requested Record
□ Passport
(Proof required if ordering a certified
□ Driver's License
Street Address (must match address on identification)
copy)
:
□ School / Sports
□ Social Security Card
City
State
Zip Code
Daytime Telephone Number
□ Social Security Disability
□ Other Social Sec. Benefits
□ Veterans Benefits
E-mail Address
□ Medicare
□ Welfare
□ Genealogy
Signature of Applicant
Date of Application
Other: _________________
Pricing:
Identification Requirements:
All applications must include one of the following:
Certificate Fees:
• Valid Photo Driver's License
Quantity
Price
Total Amount
• Photo Non-Driver's License
st
$
25.00
Certificate (1
copy)
1
$
25.00
$
0.00
Additional Copies
$
2.00
-Or two alternate forms of identification, such as:
• Non-photo State Issued Driver's License
Return Delivery
(check one):
• Vehicle Registration
Delivery Method / Processing Time
Total Amount
Price
• Insurance Card
$
0.00
Next Day (15 - 18 business days)
$
19.25
• Voter Registration
• Passport
$
0.00
2 Day (19 - 22 business days)
$
12.00
• Green Card
$
0.00
US Mail (30 - 34 business days)
No Charge
• County ID
• School ID
*VitalChek Processing Fee:
$
10.95
$
10.95
• 2 Utility Bills (within the last 90 days)
*The VitalChek processing fee is
applied per order, not per certificate
TOTAL
$
0.00
When making a copy of your photo ID, please
copy, as long as the certificates are
being shipped to the same address.
enlarge and lighten to improve legibility.
Payment Information:
Payment Method (check one):
Check
Money Order
Visa
MasterCard
American Express
Discover
Credit Card Expiration Date
Credit Card Number
Cardholder's Signature
Date
Important Note: The cardholder's billing address MUST match the shipping address provided above. Applications with credit card
payment information and proper identification documents may be faxed to: 866.233.5209.
DO NOT MAIL CASH - Make check or money order payable to VITALCHEK, PO Box 308, Brentwood, TN 37024-0308

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