Form F225d - Nova Scotia Birth Certificate Application

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F225d

Birth Certificate Application

Service Nova Scotia

and Municipal Relations

Vital Statistics

Office Use Only - Our File #

MAILING ADDRESS INFORMATION - Please Print

Surname

Given Names

Mailing Address

City

Province/State

Country

Postal Code

Civic Address (If different than above)

City

Province/State

Country

Postal Code

Home Number

Work Number

Fax Number

E-mail address

BIRTH DETAILS - Use maiden name if married - include french symbols if applicable

Surname

I I

First Name

Middle Name(s)

Male

Female

Date of Birth

Month

Day

Year

Place of Birth (City, Town, or Village)

Province

Nova Scotia

FATHER’S DETAILS - If stated on Birth Record

Surname

First Name

Middle Name(s)

Birth Place - City, Town, or Village

Province/State

Country

MOTHER’S DETAILS - Use Mother’s maiden surname (surname before marriage)

Surname

First Name

Middle Name(s)

Birth Place - City, Town, or Village

Province/State

Country

SERVICES REQUESTED - Please indicate if more than one copy is required

I I

Short Form: $28.30 per certificate

Certified copy: $34.20 per document

I I

Long Form: $34.20 per certificate

Courier Service: $20.00

Payment Type

Submitted by

Credit Card

Submitted by

I I

Cheque

Mail

Visa

American Express

Mail

In person

I I

Money Order

In person

MasterCard

Phone/Fax _____________________

I I

Credit Card - Complete credit card section on right

Credit Card Number ____________________________________________________

I I

Interac/Cash payment may only be made in person at the counter

Name as shown on credit card ___________________________________________

Expiry Date __________________________________________________________

Your Signature __________________________________________________

Cardholder Signature __________________________________________________

YOUR RELATIONSHIP TO BIRTH EVENT

I I

Self

Mother

Father

Other - Please indicate relationship

Reason Certificate required

Note: If above particulars are not completed in full, or if the correct payment per service requested is not enclosed, your request cannot be processed.

Important information on reverse

Rev. 05/07