Application For Florida Birth Record

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APPLICATION FOR FLORIDA BIRTH RECORD
Florida Department of Health in Indian River County
1900 27th Street
Vero
Beach, FL
32960-3383
TEL (772
) 794-7460 FAX (772)
794-7443
Open
Mond
ay
- Frida
y
800
AM
to
4
30
PM
TYPE OR PRINT BIRTH CERTIFICATE INFORMATION
FAX
ORDER
ONLY
e u remen
or or erm :
IT
app Icam IS
selT,
paren
,
guar lan, or ega represen a Ive, men me app Icam musl cemple e mls app lea Ion
and provide valid photo identification; if a mail reguest a
coe:l
of the valid
ehoto
identification front
&
back must be erovided.
!Acceptable forms of identification are: Driver's License State Identification Card Passport and/or Mirtarv Identification Card. If
applicant is nol one oflhe above, the Affidavillo Release a Birth Certificate must be completed by an authorized person and submitted in
add"lion to this application.
CHILD·S
FULL
NAME AS
FIRST
MIDDLE
LAST
SU
FF
IX
SHom
ON BIRTH RE
CO
RD
IF NAME WAS CHANGE
D
FIRST
MIDDL
E
CA~,
SUFFIX
SINCE BIRTH.
IND
IC
ATE
NEW
"Me
MONTH
eM
r
EAR
(4·DIGI T)
STATE
FIL
E
NUM
BER
(II
known)
~"
DATE OF BIRTH
HOS
PITAL
CI
TY
OR
T
OWN
COU
NTY
PLACE OF
BIRTH
FIRST
MIDDLE
LAST
SUFFIX
MOTHER ·S
MA.ID
EN NAME
FIRST
MIDDL
E
LAST
SUFFIX
FATHER
·S
NAME
APPLICANT (adult requesting certificate) INFORMATION
Any person wno willfully and knowir(/Iy provides any false information on a certificate. record or report required by Chapter 382. Florida Statutes.
or on any application or affidavit. or wno obtains confidential information from any Vital Record under false or fraudulent purposes. commits a
felony
of
the third degree. punishable as provided in Chapter
775.
Fiorida Statutes.
Applicant"s
Na me
FIRST
MIDDLE
LAST
(I NCLUDI
NG
ANY
SUFFIX)
TYPE OR PRINT
MA.ILl
NG ADDRESS
(I NCLUD
E
APT
NO.I
F
APP
LIC ABLE)
CITY
STATE
l
iP COD
E
HOME PH ONE
NUMB
ER
RELAT
IONSHIP
TO REGISTRANT
SIGNATUR
E OF APPLI CANT
(
(
W ORK PH ONE
NUMBER
(
(
IF
ATTORNEY.
PR
OVlDE
BAR /PR OFE
SSIO
NAL
IF
ATT
ORNEY.
PROVlDE
NAME
OF
PERS ON
YOU
REPRESENT AND
THEIR RELATIONSHIP
TO
REG
ISTRAN
T
LICENSE
NO
CHARGE: QUANTITY
FOR OFFICIAL USE ONLY:
- - -
X
$12.00
Certified Legal Document
DATE: - - - - - - - - - - - - - - -
- -
- - -
X
$10.00
Each Additional Copy
- -
- - -
X
$15.00
Express Mail Fee
IDENTIFICATION:
-------------------
- -
TOTAL
FOR FAX ORDERS ONL Y:
CERTIFICATE #S:
------------------
Credit Card Number:
-----------------
Expiration Date: ________ Security Code: _ _ _
ID
Check here if certification(s) are to be mailed to a different address. Space is provided on the reverse of
this application for indicating the name and address of the person who is to receive the certifications.
DH 1960.06/13 Obsoletes Previous Editions

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