Mason County Birth Certificate Application
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1Birth Certificate Application
Full Name at Birth (First/Middle/Last):
Date of Birth (Month/Day/Year):
City or County of Birth (Washington State Only):
Father’s Full Name (First/Middle/Last):
Mother Full Maiden Name (First/Middle/Last):
REQUESTOR INFORMATION
Name of Requestor:
Phone Number:
Street/Mailing Address:
City / State:
Zip:
Signature of Requestor:
[ ] Pre-Order Pick Up between 4:00 & 4:30
[ ] Pre-Order Mail to above address
[ ] In-Person
($3 Expedite fee)
PAYMENT INFORMATION
PROCESSING FEES APPLY TO ALL PAYMENTS MADE BY DEBIT/CREDIT CARD IN THE AMOUNT OF $2.00 OR
2.5% WHICHEVER IS GREATER. We accept Cash, Check (made out to Mason County Treasurer), Visa, Mastercard,
Discover, American Express, & Debit
Number of Certificates:
_____ X $20.00
= $_______
(If paying by credit card, ADD $2.00 or 2.5% whichever is greater)
Expedite fee:
_____ X $3.00
Amount Paid:
[ ] Cash
[ ] Check (Payable to MCT)
[ ] Credit/Debit (processing fee)
$_________
APPLICATION SUBMITTAL
Applications may be submitted by:
Contact Information:
Mail or In-Person to:
Phone: (360) 427-9670 x400 Shelton
Mason County Public Health
(360) 275-4467 x400 Belfair
th
415 N. 6
Street, Shelton, WA 98584
(360) 482-5269 x400 Elma
Fax:
(360) 427-7787
FOR OFFICE USE ONLY
Date Picked up/Mailed: _________________________
Receipt #: ____________________________
Completed by: ________________________ Certificate #(s): ____________________________________________________
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