VitalChek logo Connecticut Dept. Of Public Health
Civil Union Certificate
Print this form, complete it and fax it to 8662033115
Party A's Name ______________________________________________________________________
 (first middle last)
 
Party B's Name ______________________________________________________________________
 (first middle last)

Date of Civil Union___________________________ City ____________________________State_______

Relationship:   Self  Mother  Father  Other ________________________________

Reason for request_________________________________________Number Of Copies_______

Ship Method: Express Courier (additional charges)  Express Courier 3 Day (additional charges)


Ship To Name
______________________________________________________________________

Address
______________________________________________________________________

City
__________________________________________ State ________ Zip _________

Phone Number
__________________________________________


Credit Card: Visa   MasterCard    American Express   Discover

Credit Card Number _____________________________________________________   Expires _____________

Cardholder's Signature
_____________________________________________________  Date _____________

Cardholder's Address
_________________________________________________________________________________

City
________________________________________________ State ________ Zip ______________

Applicant's Signature
_____________________________________________________  Date _____________

Applicant's Email:
_____________________________________________________
Photo identification not required, unless Social Security Number is being requested. Only partners to the civil union are authorized to obtain a copy with SSN, valid government issued identification would be required.