Application for Alberta Birth Certificate - VitalCertificates.ca

Application for Alberta Birth CertificateAlthough you can fill out the application online, you cannot save or email it. Please type, print and sign the application then fax, scan and emailor mail your application to us. A receipt, along with your order information, will be issued and sent to you by email or mail.Important Note: Applications are processed upon receipt. As such, we cannot change or cancel applications once received.Contact Information (For Non-Alberta residents only. If you currently reside inAlberta please telephone 1-780-427-7013)Full Name: _______________________________________________________________Daytime Telephone: (_______) ______________________ Extension: ________ Home Telephone: (_______) ______________________Mailing Address: ___________________________________________________________________ Apartment: ________City: ______________________ Prov./State: _____________________ Country: ___________________ Postal/Zip Code: ____________Email Address: _________________________________________________ (If no email address is provided, your receipt will be mailed to you)ApplicationYou must enter as much information as possible. If information is missing or does not match the original birth registration theremay be delays in processing your application. If there has been a legal name change, please provide the new legal name. Ifadopted, please list the adopted parents’ names. If you are legal counsel or a legal guardian please telephone 1-780-415-2225.Reason Certificate Required: ________________________________________________Name : ____________________________ ____________________________ ____________________________ Male FemaleFirst Middle Last (at birth)Date of Birth: __________________ _____ ________ Place of Birth: ____________________________, ALBERTAMonth Day Year City/TownName of Hospital Where Birth Occurred: _____________________________________________Father/Co-Parent’s Name: ____________________________ ____________________________ ____________________________First Middle Last (at birth)Place of Birth: ____________________________ ____________________________ ____________________________City/Town Province CountryMother’s Name: ____________________________ ____________________________ ____________________________First Middle Last (mother’s maiden name)Place of Birth: ____________________________ ____________________________ ____________________________City/Town Province CountryPayment InformationCertificates take approximately 10 to 15 business days to be processed and delivered. All delivery times quoted are average delivery times,and cannot be guaranteed. All taxes and shipping costs are included. Please see website for description of each version of certificate.____ Qty. - Family Information Birth Certificate - $90.00 each____ Qty. - Individual Information Birth Certificate - $90.00 each____ Qty. - Certified Photocopy of Birth Registration - $90.00 eachRush Service - 4 to 7 business days (includes mailing time - is not couriered) - $30.00 additional Vital Statistics ‘Rush’ processing feeCredit Card Type: (or) Phone me for credit card details (cardholder must still sign below).Credit Card Number: _____________________________________________Exp. Date: ___________Name of Cardholder: ________________________________________ Signature: _______________________________________If paying by money order or certified cheque please mail the completed application along with your payment. Personal cheques will besubject to bank clearing and may take up to 7 days. Applications received with a personal cheque will be held until such time as thecheque clears. Payment must be made payable to ‘Express Legal’. Any questions, please telephone us toll-free at 1-866-828-9680.Please return your completed application and authorization to us by one of the following methods:Toll-Free Fax: 1-866-265-6300, Scan & Email: support@expresslegal.caor Regular Mail: Express Legal, 79 - 622 Front Street, Nelson, BC V1L 4B7continued on next page

Birth CertificateAuthorizationRegistryConnect10237 – 104 St.Edmonton,ABT5J 1B1Towhomitmayconcern,RE:ApplicationforBirthCertificateI, _________________________________________ authorize David Shelly, to obtainone or more(provide full name)birthcertificate(s). I am the person, or parent of the person, who is the subject of the certificate.My home address is:Address: ___________________________________________ Apartment: _______City: _________________________ Prov./State: _________________________Postal/Zip Code: _______________ Country: _________________________My home phone number is:(______) ________________________Pleasehavemycertificate(s) senttomyhomeaddress.Sincerely,Date: ____________________Signature: ________________________________(signature must be provided)ImportantNote:DonotmailthisauthorizationlettertoRegistryConnect.Please return by one of the following methods:Toll-Free Fax: 1-866-265-6300, Scan & Email: support@expresslegal.caor Regular Mail: Express Legal, 79 - 622 Front Street, Nelson, BC V1L 4B7