Print Form
Birth Certificate Request Form
City of Ashtabula Health Department
Name at Birth:
Date of Birth:
Mother’s Maiden Name:
Father’s Name:
Person Making Request:
Requestor’s Address:
City:
State:
Zip:
Contact Phone:
Requestor’s Signature:
Print this form, sign it and mail along with a check for $25.00 and a self- addressed stamped envelope to:
Ashtabula City Health Department
4717 Main Avenue
Ashtabula, Ohio 44004
OR
We accept Visa & Mastercard & Discover. There is a $3.00 convenience fee for use of credit card.
You may call in your credit card information to (440) 992-7123 or print this form, sign it and fax it to
440-992-7163 along with a copy of your credit card (front & back) and fill out the information below:
Visa
Mastercard
Discover
Name on Card:
Account #:
Exp Date:
Billing Phone:
3 Digit V Code on Back of Card:
Billing Address:
City:
State:
Zip:
Cardholder Signature:
* By signing this you are authorizing the City of Ashtabula to debit your account for the charges due.
You will be charged $25 for the certified copy, $3.00 convenience fee on use of credit card and postage.
Please check the type of postage you prefer:
Regular Mail $0.49*
Priority Mail $5.60*
Express Mail $19.99*
*These fees are charged according to what the USPS is charging at the time of the order.
Print Form
Birth Certificate Request Form
City of Ashtabula Health Department
Name at Birth:
Date of Birth:
Mother’s Maiden Name:
Father’s Name:
Person Making Request:
Requestor’s Address:
City:
State:
Zip:
Contact Phone:
Requestor’s Signature:
Print this form, sign it and mail along with a check for $25.00 and a self- addressed stamped envelope to:
Ashtabula City Health Department
4717 Main Avenue
Ashtabula, Ohio 44004
OR
We accept Visa & Mastercard & Discover. There is a $3.00 convenience fee for use of credit card.
You may call in your credit card information to (440) 992-7123 or print this form, sign it and fax it to
440-992-7163 along with a copy of your credit card (front & back) and fill out the information below:
Visa
Mastercard
Discover
Name on Card:
Account #:
Exp Date:
Billing Phone:
3 Digit V Code on Back of Card:
Billing Address:
City:
State:
Zip:
Cardholder Signature:
* By signing this you are authorizing the City of Ashtabula to debit your account for the charges due.
You will be charged $25 for the certified copy, $3.00 convenience fee on use of credit card and postage.
Please check the type of postage you prefer:
Regular Mail $0.49*
Priority Mail $5.60*
Express Mail $19.99*
*These fees are charged according to what the USPS is charging at the time of the order.
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