Application for a birth certificate

Please print application form and complete.

Please read notes before completing

1. Applicant

Name of applicant: Mr/Mrs/Miss/Ms (State name in full)
Full postal address:
Post Code:	Telephone No:

2.

It would help us if you would state the purpose for which the certificate is required:

3.

Are you applying for your own birth certificate?	YES / NO
If not please state your relationship to the person to whom the certificate relates:

4. Details of birth certificate required

Full Name at Birth	Father's Full Name	Mother's Full Name
Surname	Surname	Surname
Forename(s)	Forename(s)	Forename(s)
		Maiden Surname

Date of birth			Place of birth (Full address or name of hospital)
Day	Month	Year

5. Requirements

	I require     (number) standard birth certificate(s)
	I require   (number) short birth certificate(s)

6.

Signature:

Date:

7. Remittance enclosed

I enclose a cheque/postal order made payable to Durham County Council, in sterling drawn on a British Bank Sorting Code, for £

FOR REGISTER OFFICE USE ONLY
Register No. - Entry No. - District		Certificate No.
Date of issue: