South Carolina Vital Records Birth Certificate Long Form Print this form, complete it and fax it to 8772841084

Certificate Holder's Name ____________________________________________________________________________   (first middle last) Father's Name ____________________________________________________________________________   (first middle last) Mother's Maiden Name ____________________________________________________________________________   (first middle last) Date of Birth __________________ County/City __________________________________ State_______ Hospital __________________________________________________________ Male  Female Parent's Married?   Yes  No Relationship: Self  Mother   Father  Other ________________________________________ Reason for request __________________________________________________ Number Of Copies _______ Ship Method: Express Courier (additional charges)  Regular Mail Ship To Name _________________________________________________________________________________ Address _________________________________________________________________________________ City ________________________________________________ State ________ Zip ______________ Daytime Phone ____________________ Credit Card: Visa   MasterCard    American Express   Discover Credit Card Number _____________________________________________________ Expires _____________ Cardholder's Signature _____________________________________________________   Date _____________ Applicant's Signature _____________________________________________________   Date _____________ Applicant's Email _____________________________________________________ Applicant's DOB ______________     SSN (last 4 digits)  __________