VitalChek logo Connecticut Dept. Of Public Health
Certification Of Birth (Wallet Size)
Print this form, complete it and fax it to 8662033115
Certificate
Holders Name
____________________________________________________________________________
 (first middle last)

Father's Name
____________________________________________________________________________
 (first middle last)
Mother's Maiden
Name
____________________________________________________________________________
 (first middle last)

Date of Birth__________________ County/City __________________________________State_______

Gender:     Male  Female

Relationship: Self  Mother   Father  Other ________________________________________

Reason for request__________________________________________________Number Of Copies_______

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

Ship To Name
_________________________________________________________________________________

Address
_________________________________________________________________________________

City
________________________________________________ State ________ Zip ______________

Daytime Phone
____________________

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:
_____________________________________________________

Valid state-issued photo ID or passport required;
OR
2 forms of alternate ID such as:
Non-photo State Issued Drivers License, Social Security Card, Written Verification of Identity From Employer, Vehicle Registration, Voter Registration, Green Card, or Utility Bill(s) showing name and address.