D.C. Vital Records Birth Certificate Print this form, complete it and fax it to 8775532119

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 Relationship: Self  Mother   Father  Other ________________________________________ Reason for request __________________________________________________ Number Of Copies _______ Ship Method: FedEx Priority   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) __________ Credit Card Billing Address Name ______________________________________________ Address ____________________________________________ City _________________________ State ____ Zip ________