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Version
09/2020
Alaska BIRTH Certificate Request Form
• Please read the instructions on the first page. Incomplete or inaccurate requests that do not include a copy of a government issued ID will not be
processed.
• Submit this form WITH PAYMENT in person (Cash, check, money order or credit card), by mail (check, money order, or credit card), or by fax (credit
card only). Office locations and contact information is on instruction page.
• This form is only for the purpose of the financial transaction and location of the requested record
• Please make Checks/Money Orders payable to: ALASKA VITAL RECORDS OFFICE.
• There will be a $30 NSF fee for returned checks.
Information needed to locate the record:
FIRST Name on the Birth Certificate
MIDDLE Name
LAST/FAMILY Name
Date of Birth _________________________________________________
City/Village of Birth ___________________________________________
Mother's Full Name Prior to Marriage
Father's Full Name
APPLICANT NAME:
_____________________________________________
Contact Phone Number _________________________________________
Contact E-mail Address __________________________________________
Mailing Name ___________________________________________________
Mailing Address:
Street/P.O. Box _________________________________________________________
City, State, Zip __________________________________________________________
Choose your Relationship to Child Named on the Record:
___ Self ___ ___ Parent Legal representative (with documentation)
___ Other (Please specify) ____________________________________
Purpose of request
(Ex: Personal records, legal purposes, government benefits, etc.)
Signature of Person Requesting the Record (Electronic/Typed Signature NOT
Accepted)
What would you like to order?
_____ Number of Certified Birth Certificates
_____
_____
($30 one copy, $25 each additional copy of the same record ordered at the same time)
Paternity, Correction, Adoption, or Legal Name Change Processing Fee ($30)
Apostille Fee ($12 for first copy, $2 each additional copy)
Apostille Country: ___________________________________________
_____ Number of Heirloom Certificates ($55 first copy; $50 additional copies)
Choose one:
___ Rie Munoz, “The Embrace
___ Jon VanZyle, “Polar Bears”
_____ *Expedited/Rush Service (Fax/Email orders) ($11)
Please note: If birth is not registered or has an administrative hold, it cannot be rushed
How would you like it shipped?
Please note: Alaska Vital Records assumes no responsibility for items after they have been shipped. If documents are lost or
stolen you will need to resubmit your order with ID and payment. Vital Record certificates are legal documents that should
be in your control only. Lost certificates may end up in the hands of criminals who could use the certificate to steal your
identity. HAVRS strongly recommends you choose a method of shipping that requires a signature upon receipt. Call
907-465-3391 for more information on International Shipping.
Choose one:
_____ Regular Mail (No fee, NO tracking available!)
_____ Priority Mail ($9.00. Includes tracking. No signature required).
_____ Priority Mail ($12.00. Includes tracking and signature).
_____ FedEx Alaska (No P.O. Boxes; $25.00. Includes tracking and signature).
Do you want a signature?
Yes
No
_____ FedEx USA (No P.O. Boxes; $30.00. Includes tracking and signature).
Do you want a signature? Yes
No
Total for all Items
Credit Card Information
(We accept: Visa, MasterCard, Discover, and American Express)
Name on Credit Card _________________________________________
Credit Card Number __________________________________________
Expiration date ______________________________________________
Zip Code ___________________________________________________
Cardholder Signature (REQUIRED; ELECTRONIC/TYPED SIGNATURE NOT
ACCEPTED) _________________________________________________
2 Click to Clear Form___
