Application for a birth certificate DCC Logo

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:
It would help us if you would state the purpose for which the certificate is required:  
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)
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 £
Register No. - Entry No. - District
Certificate No.
Date of issue: