Birth Certificate Application - Nova Scotia Canada

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F225d
Birth Certificate Application
Service Nova Scotia
and Municipal Relations
Vital Statistics
Office Use Only - Our File #
MAILING ADDRESS INFORMATION - Please Print
Surname
Given Names
Mailing Address
City
Province/State
Country
Postal Code
Civic Address (If different than above)
City
Province/State
Country
Postal Code
Home Number
Work Number
Fax Number
E-mail address
BIRTH DETAILS - Use maiden name if married - include french symbols if applicable
Surname
I I
I I
First Name
Middle Name(s)
Male
Female
Date of Birth
Month
Day
Year
Place of Birth (City, Town, or Village)
Province
Nova Scotia
FATHER’S DETAILS - If stated on Birth Record
Surname
First Name
Middle Name(s)
Birth Place - City, Town, or Village
Province/State
Country
MOTHER’S DETAILS - Use Mother’s maiden surname (surname before marriage)
Surname
First Name
Middle Name(s)
Birth Place - City, Town, or Village
Province/State
Country
SERVICES REQUESTED - Please indicate if more than one copy is required
I I
I I
Short Form: $28.30 per certificate
Certified copy: $34.20 per document
I I
I I
Long Form: $34.20 per certificate
Courier Service: $20.00
Payment Type
Submitted by
Credit Card
Submitted by
I I
I I
I I
I I
I I
I I
Cheque
Mail
Visa
American Express
Mail
In person
I I
I I
I I
I I
Money Order
In person
MasterCard
Phone/Fax _____________________
I I
Credit Card - Complete credit card section on right
Credit Card Number ____________________________________________________
I I
Interac/Cash payment may only be made in person at the counter
Name as shown on credit card ___________________________________________
Expiry Date __________________________________________________________
Your Signature __________________________________________________
Cardholder Signature __________________________________________________
YOUR RELATIONSHIP TO BIRTH EVENT
I I
I I
I I
I I
Self
Mother
Father
Other - Please indicate relationship
Reason Certificate required
Note: If above particulars are not completed in full, or if the correct payment per service requested is not enclosed, your request cannot be processed.
Important information on reverse
Rev. 05/07
F225d
Birth Certificate Application
Service Nova Scotia
and Municipal Relations
Vital Statistics
Office Use Only - Our File #
MAILING ADDRESS INFORMATION - Please Print
Surname
Given Names
Mailing Address
City
Province/State
Country
Postal Code
Civic Address (If different than above)
City
Province/State
Country
Postal Code
Home Number
Work Number
Fax Number
E-mail address
BIRTH DETAILS - Use maiden name if married - include french symbols if applicable
Surname
I I
I I
First Name
Middle Name(s)
Male
Female
Date of Birth
Month
Day
Year
Place of Birth (City, Town, or Village)
Province
Nova Scotia
FATHER’S DETAILS - If stated on Birth Record
Surname
First Name
Middle Name(s)
Birth Place - City, Town, or Village
Province/State
Country
MOTHER’S DETAILS - Use Mother’s maiden surname (surname before marriage)
Surname
First Name
Middle Name(s)
Birth Place - City, Town, or Village
Province/State
Country
SERVICES REQUESTED - Please indicate if more than one copy is required
I I
I I
Short Form: $28.30 per certificate
Certified copy: $34.20 per document
I I
I I
Long Form: $34.20 per certificate
Courier Service: $20.00
Payment Type
Submitted by
Credit Card
Submitted by
I I
I I
I I
I I
I I
I I
Cheque
Mail
Visa
American Express
Mail
In person
I I
I I
I I
I I
Money Order
In person
MasterCard
Phone/Fax _____________________
I I
Credit Card - Complete credit card section on right
Credit Card Number ____________________________________________________
I I
Interac/Cash payment may only be made in person at the counter
Name as shown on credit card ___________________________________________
Expiry Date __________________________________________________________
Your Signature __________________________________________________
Cardholder Signature __________________________________________________
YOUR RELATIONSHIP TO BIRTH EVENT
I I
I I
I I
I I
Self
Mother
Father
Other - Please indicate relationship
Reason Certificate required
Note: If above particulars are not completed in full, or if the correct payment per service requested is not enclosed, your request cannot be processed.
Important information on reverse
Rev. 05/07
F225d
IMPORTANT INFORMATION
To Avoid Delay
• Complete all sections in full. (All requests with incomplete information must be accompanied by a written explanation for the
omission. If any portion of the relevant event information is left blank, the application will be returned for completion.
• Be sure you are authorized to make the request (see Section 3 below)
• It is against postal regulations to send cash through the mail. Payment in Canadian funds should be forwarded by cheque, bank
draft or money order made payable to the Minister of Finance.
• If you are paying by credit card, include the card number, expiry date, and the actual name of the cardholder that appears on the
card. NOTE: Only Visa, MasterCard and American Express are accepted.
• Be sure your address and telephone number are correct and clear.
1) Fees - As noted for each requested copy on the front of this form.
2) Information provided
Certificates contain the following information:
a) Short Form: Full name, sex, date of birth, place of birth, registration date, registration number, and date issued.
b) Long Form: Full name, sex, date of birth, place of birth, registration date, registration number, date issued, names of parents,
and birthplaces of parents.
c) Certified Copy: All the information which appears on the original registration, including full name, sex, date of birth, place of
birth, registration date, registration number, date issued, names of parents, birthplaces of parents, plus other information, for
example, the name of the person who assisted at the birth, birth weight, etc.
NOTE: Certified copies are generally only required for court purposes. They are not for use as identification.
3) Who qualifies to apply for a Birth Certificate
Birth certificates may be released to:
a) You, if the record pertains to your own birth
b) Parents of a child
c) A lawyer who specifically indicates they are working on behalf of “a” or “b” above, or a person on the written authorization of
“a” or “b” above
d) The executor/executrix or trustee of an estate.
e) Guardian (copy of guardianship papers must be attached to this application)
Other Services
Death and marriage certificates, legal change of name, domestic partnership registrations, and genealogy searches. To obtain an
application for any of these services, please visit one of our offices, or contact us by telephone at 1-877-848-2578 or on the internet
at: http://www.gov.ns.ca/snsmr/vstat
The information on this form is collected under the authority of the Vital Statistics Act (Revised Statutes of Nova Scotia 1989, chapter 494).
The information provided will be used to fulfill the requirements of the Vital Statistics Act for the release of birth information. If you have
any questions about the collection or use of this information, please contact Vital Statistics at 1-877-848-2578.
Mailing Address:
Or Visit Our Office:
Vital Statistics
Vital Statistics Office - Joseph Howe Building
P.O. Box 157
1690 Hollis Street
Halifax, Nova Scotia
Halifax, Nova Scotia
B3J 2M9 Canada
B3J 2M9 Canada
Enquiries:
Hours: 8:30 a.m. to 4:30 p.m. Monday to Friday, except holidays.
Local: (902) 424-4381
Toll Free: 1-877-848-2578 (Nova Scotia only)
Fax: (902) 424-4143
Website and ordering online: http://www.gov.ns.ca/snsmr/vstat
E-mail: vstat@gov.ns.ca

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