Number of Certificates Ordering: ________ certified copies @ $20.00 each (plus $12.50 handling fee per order)
______________________________________________________________ _(______)______________________________
Your Name Daytime Phone
______________________________________________________________ _______________________________________
Company Name (if applicable) Email Addresss (optional)
______________________________________________________________ _______________________________________
Address Your Relationship to the Person on the Certificate
_______________________________________________________________________________________________________
City State Zip Code Country
Name on Certificate: ________________________________________________________________________________________
First Name(s) Middle Name(s) Last Name(s)
Date of Birth:
__________________________ City or County of Birth: _______________________________ Male
Female
Father/Parent Birth Name: __________________________________________________________________________________
First Name(s) Middle Name(s) BIRTH LAST NAME(S)
Mother/Parent Birth Name: _________________________________________________________________________________
First Name(s) Middle Name(s) BIRTH LAST NAME(S)
Select shipping method: US Mail -or-
UPS rush delivery, signature required, additional fee of $18.50, cannot deliver to PO Boxes
* If you wish to ship to a different address, please complete the section below:
_____________________________________________________________ _(______)__________________
Name Daytime Phone
_____________________________________________________________
Address Line 1
_____________________________________________________________
Address Line 2 (optional)
______________________________________________________________________________________
City State Zip Code Country
Card number: ________________________________________________________ Exp date: __________________
Select card name/billing address: same as Applicant -or-
same as Shipping -or- complete below
_______________________________________________________________________
Name
_______________________________________________________________________
Billing Address City State Zip Code Country
Please Note: Any time a record is searched for and is not found, an $8.00 search fee is charged per the Revised Code of Washington (RCW 70.58.107).
Contact King County Vital Statistics at 206-897-5100 if you have questions or need assistance.
Birth Certificate Fax Order Form 206-897-4580
Certificate Information (exact and complete information required)
Payment Information (credit and debit cards accepted)
