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: