APPLICATION FOR A BIRTH CERTIFICATE PLEASE READ THESE NOTES before completing this form.

Birth Certificate East Staffordshire : BOT/068/005

1 TO BE COMPLETED BY THE APPLICANT Name of applicant Mr Mrs Miss/Ms (STATE NAME IN FULL) Full postal address   Post Code: Telephone no: e-mail address:

2 Are you applying for your own birth certificate? Yes/No If not please state your relationship to the person:

3 DETAILS OF BIRTH CERTIFICATE REQUIRED
FULL NAME AT BIRTH			FATHER'S FULL NAME	MOTHER'S FULL NAME
FORENAME(S) Alice J			FORENAME(S)	FORENAME(S)
SURNAME MORTLOCK			SURNAME	SURNAME
				MAIDEN SURNAME
DATE OF BIRTH			PLACE OF BIRTH (Full address or name of hospital)
DAY	MONTH	YEAR 1880	Burton-on-Trent

4 REQUIREMENTS	Send this Application to:
BIRTH CERTIFICATE £11.00	Superintendent Registrar, Register Office, Castle House, Barracks Road, Newcastle-Under-Lyme, Staffordshire, ST5 1BL, UK
I requireNUMBER birth certificate(s)

5 REMITTANCE ENCLOSED  (POSTAL APPLICATIONS ONLY)
Payment by Credit Card only : Please add £2.00 for Post and Packaging, i.e. a total of £13.00 per certificate. A Priority Service is available for £35.00 + £2.00 for Post and Packaging.
If paying by Credit Card: Please debit my account by the amount: £		Type of card (e.g. Visa, Mastercard or Switch):
Name on Card:		Card Expiry Date (DD/MON/YYYY):
Enter both Card Number & Security Code. Card Number:                                       Security Code:
Signature:   Date:   Card Issue No. : (Switch only) Card Start Date (DD/MON/YYYY): (Switch only)
The Fee for a certificate issued against this form 'as printed' will not be refunded. You are strongly recommended to add any qualifying information you may have in order to help the registrar issue the correct certificate.