Application for a birth certificate
Your full name Title * Mr
Last name
Derby Register Office Royal Oak House Market Place Derby DE1 3AR Tel: 01332 256526 Fax: 01332 256525 Minicom: 01332 256666 E-mail: registeroffice@derby.gov.uk Web: www.derby.gov.uk
Please use a black ball-point pen and write in the squares using capital letters. * indicates mandatory information.
Mrs Miss Ms Other Please specify:
First name
*
*
House no or name Street Town City County
*
Relationship to person named below * Reason for applying for certificate *
Postcode E-mail address
*
Details of birth certificate required
Last name
Name of Person at birth
*
First name
*
Full address or name of hospital/maternity home *
Date of birth
*
/
* * *
/
Last name
First name
Father's name
Last name First name
* * *
Mother's name Mother's maiden name Last name
First name
I require I require
standard birth certificate(s) at £7.00 each = short birth certificate(s) at £5.50 each =
£ £
I enclose a cheque/ postal order/ sterling bankers draft/ sterling money order for the sum of £ made payable to Derby City Council. Alternatively, if you wish to pay for this service by debit card only please telephone 01332 716020 with your card details. Please note that the short birth certificate is no longer suitable for a UK passport application. Signature of applicant * For Office Use Only Application ref no Register no Date of application
*
/
/
Entry no Certificate no
We will treat all information provided in confidence and in accordance with the Data Protection Act 1998. It will not be shared with any other department and we will only use it to provide you with a copy certificate. RBC01 1394551187