Yukon Birth Certificate Application - VitalCertificates.ca

Yukon Birth Certificate ApplicationThis application is to obtain a birth certificate for subjects born in the YukonFor help completing the application please see page 3 “Birth Certificate Application Completion Instructions”.Although you can fill out the application online, you cannot save or email it. Please type, print and sign the application then fax, scan andemail or mail your application to us.Applications are processed upon receipt. As such, we cannot change or cancel applications once received.Contact InformationName: ____________________________________________ApplicantTelephone Number: (_____) ___________________ Ext: ________Firm/Organization: ____________________________________________Complete only if certificate to be delivered hereDaytime Number: (_____) ___________________ Ext: ________Mailing Address: _______________________________________________________Apt.: __________ _ Buzzer Code:____________City: _________________________ Prov./State: _________________ Country: _________________ Postal/Zip Code:________________If required, I prefer to be contacted by: Email TelephoneEmail Address: ________________________________________________________Receipt will be mailed if no email providedApplicationReason Certificate Required: ________________________________________________________________________________________Please Specify ReasonSubject Name: _______________________ ______________________ _______________________ Male FemaleFirst Middle Last (at birth)Date of Birth: ____________________ _________ _________Month Day Year City/TownFather/Co-Parent Name: _____________________________ _____________________________Place of Birth: ______________________________________, YukonFirst Middle Last (at birth)Place of Birth: ____________________________________ _____________________________City/Town Province/State CountryMother’s Name: ___________________________________ _____________________________First Middle Last (at birth)Place of Birth: ____________________________________ _____________________________City/Town Province/State CountryNumber of Older Siblings at Time of Birth (born to this mother): _____________________________Payment Information________________________________________________________________________________________________________________________Certificates take approximately 10 to 15 days to be processed and delivered. Delivery times are average delivery times and cannotbe guaranteed. All taxes and shipping included.____ Qty. - Small Birth Certificate (Wallet Size) - $60.00 each____ Qty. - Large Birth Certificate (Framing Size) - $60.00 each (includes parent’s names and birthplaces)Credit Card Type: (or) Phone me for credit card details (cardholder must still sign below).Credit Card Number: _____________________________________________ Exp. Date: _______________________________________Name of Cardholder: _____________________________________________ Cardholder Email: _________________________________Type/Print NameSignature: ______________________________________________________ Date: ____________________________Charge will appear as “Express Legal” on credit card statement.If paying by money order or certified cheque, please mail the completed application along with your payment.Any application received with a personal cheque will be held until such time as the cheque clears, typically 7 to 10 days.Cheques and money orders must be made payable to “Express Legal”.

Birth Certificate Application Completion InstructionsAVOID DELAYS: Enter as much information as possible. If information is missing or does not match the original birth registrationthere may be delays in processing your application.WHO CAN APPLYYukon birth certificates may be released to:1. The person whose birth is registered; or2. A person whose name appears as a parent on the registration of the birth, if the person whose birth is registered is 18 years ofage or younger; or3. A guardian of the person whose birth is registered, if the person whose birth is registered is 18 years of age or younger(custodial guardians must provide a copy of guardianship papers); or4. A person who has written authorization from a person described above.CONTACT INFORMATIONApplicant: Person completing the application and signing the authorization.Subject: Person named on certificate.If you are applying for your own birth certificate, you are both the subject AND the applicant.If information is missing from the application or if additional information is required, we will contact the applicant by telephone oremail. Please indicate whether you prefer to be contacted by telephone or email.APPLICATIONReason Certificate Required: Please specify why birth certificate is needed (Example: Lost, Passport Application, Damagedetc...).Legal Name: If there has been a legal name change, please use the new legal name. Assuming your spouse’s name is not a legalname change. If either parent has had a legal name change prior to the subject’s birth please provide new legal name.Adoption: If subject was adopted, please list the adopted parents’ names.Father/Co-Parent: Must be last name at birth. The father/co-parent information must be included on this application if the informationappears on the child’s original birth registration.Mother: Must be last name at birth (maiden name).PAYMENT INFORMATIONShort Form - Individual Birth Certificate (Wallet Size): contains individual’s name, date of birth, place of birth, sex, registrationdate and registration number.Long Form - Family Information Birth Certificate (Framing Size): contains individual’s name, date of birth, place of birth, sex,parent(s) name(s) and their birthplace(s), registration date and registration number.A receipt, along with your order information, will be issued and sent to you by email or mail.Please return your completed application andauthorization to us by one of the following methods:Toll-Free Fax: 1.866.265.6300Scan & Email: support@expresslegal.caor Regular MailExpressLegal, 79-622 Front Street, Nelson, BC V1L 4B7Toll-Free Telephone: 1.866.828.9680