Form VS-11 "Application for Certified Copy of Birth Certificate" - Arizona

What Is Form VS-11?

This is a legal form that was released by the Arizona Department of Health Services - a government authority operating within Arizona. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2018;
  • The latest edition provided by the Arizona Department of Health Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form VS-11 by clicking the link below or browse more documents and templates provided by the Arizona Department of Health Services.

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Download Form VS-11 "Application for Certified Copy of Birth Certificate" - Arizona

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Bureau of Vital Records Request for Copy of Birth Certifi cate
For Offi ce Use Only—State File Number/Serial Number
Order Number
CUSTOMER MAIL IN CHECKLIST
Please visit the Bureau of Vital Records website https://azdhs.gov/
Clear photocopy of the front and back of your valid, signed
licensing/vital-records/index.php for the following information:
government photo ID OR have your signature notarized
Fees
Proof of relationship enclosed if required (birth certificates,
Locations, office hours, and availability of services
certified court documents, etc)
Eligibility requirements and acceptable identification
Correction, amendment, and registration information
Sign the application/Original signature required
Download forms
Include self-addressed stamped envelope
Telephone: 602-364-1300
Correct fee enclosed - https://azdhs.gov/licensing/vital-
Apply Online: www.VITALCHEK.com
(Refer to website for their current fees)
records/index.php#local-county
Today's Date
# of Certifi ed
# of Non-certifi ed
Purpose of Request
Payment Method
Copies Requested
Genealogy copies
requested
Payment Information
/
Visa
MC
Card Number _______ - _______ - _______ - _______
Card Expiration Date
Billing Zip Code ______________
CCV# _______
Signature of Cardholder
Amount to be Charged
— Must provide photocopy of valid government issued identifi cation if cardholder is not the applicant.
$
Date of Birth
Sex
Name on Birth Certifi cate
Male
Female
First
Middle
Last
Town/City of Birth
County
Hospital
Mother’s/Parent’s First Name
Middle
Last Name prior to fi rst marriage
Date of Birth
State (if US) or Country of birth
Father’s/Parent’s First Name
Middle
Last
Date of Birth
State (if US) or Country of birth
Do you belong to an Arizona Tribe?
If yes, please specify tribe.
Yes
No
Applicant's Full Name—Printed
Applicant’s
Signature—Required
First
Middle
Last
Mailing Address
Street
City
State
Zip
Daytime Telephone Number
Email Address
Your Relationship to Person on Certifi cate—Check One
*PROOF of relationship MUST be provided if you are NOT named on the certifi cate.
Parent
Self
Brother/Sister
Grandparent
Legal Guardian
Spouse
Gov’t Agency
Other
Documentation must be provided to support eligibility.
Applicable only if no government issued photo ID is available
State of
County of
On this
day of
, 20
before me personally appeared
(name of signer), whose identity was proven to me
Affi x Seal/Stamp Here
on the basis of satisfactory evidence to be the person whose name is subscribed to this document, and who
acknowledges that he/she signed the above document.
Notary Signature
My Commission Expires
VS-11 (10/18)
RESET
PRINT
SAVE AS
Bureau of Vital Records Request for Copy of Birth Certifi cate
For Offi ce Use Only—State File Number/Serial Number
Order Number
CUSTOMER MAIL IN CHECKLIST
Please visit the Bureau of Vital Records website https://azdhs.gov/
Clear photocopy of the front and back of your valid, signed
licensing/vital-records/index.php for the following information:
government photo ID OR have your signature notarized
Fees
Proof of relationship enclosed if required (birth certificates,
Locations, office hours, and availability of services
certified court documents, etc)
Eligibility requirements and acceptable identification
Correction, amendment, and registration information
Sign the application/Original signature required
Download forms
Include self-addressed stamped envelope
Telephone: 602-364-1300
Correct fee enclosed - https://azdhs.gov/licensing/vital-
Apply Online: www.VITALCHEK.com
(Refer to website for their current fees)
records/index.php#local-county
Today's Date
# of Certifi ed
# of Non-certifi ed
Purpose of Request
Payment Method
Copies Requested
Genealogy copies
requested
Payment Information
/
Visa
MC
Card Number _______ - _______ - _______ - _______
Card Expiration Date
Billing Zip Code ______________
CCV# _______
Signature of Cardholder
Amount to be Charged
— Must provide photocopy of valid government issued identifi cation if cardholder is not the applicant.
$
Date of Birth
Sex
Name on Birth Certifi cate
Male
Female
First
Middle
Last
Town/City of Birth
County
Hospital
Mother’s/Parent’s First Name
Middle
Last Name prior to fi rst marriage
Date of Birth
State (if US) or Country of birth
Father’s/Parent’s First Name
Middle
Last
Date of Birth
State (if US) or Country of birth
Do you belong to an Arizona Tribe?
If yes, please specify tribe.
Yes
No
Applicant's Full Name—Printed
Applicant’s
Signature—Required
First
Middle
Last
Mailing Address
Street
City
State
Zip
Daytime Telephone Number
Email Address
Your Relationship to Person on Certifi cate—Check One
*PROOF of relationship MUST be provided if you are NOT named on the certifi cate.
Parent
Self
Brother/Sister
Grandparent
Legal Guardian
Spouse
Gov’t Agency
Other
Documentation must be provided to support eligibility.
Applicable only if no government issued photo ID is available
State of
County of
On this
day of
, 20
before me personally appeared
(name of signer), whose identity was proven to me
Affi x Seal/Stamp Here
on the basis of satisfactory evidence to be the person whose name is subscribed to this document, and who
acknowledges that he/she signed the above document.
Notary Signature
My Commission Expires
VS-11 (10/18)
PARTICIPATING OFFICE LOCATIONS
The Bureau of Vital Records does not provide walk-in service for birth certifi cate issuance. Services available at the Bureau of
Vital Records by appointment only are delayed birth registration, adoptions, foreign born, putative father, and amendments and
corrections for births that occurred prior to 1997.
Please note payment types accepted at various offi ce locations: Cash (C) - in person only, Money Order/Cashier’s Check (MO),
Personal Check (PC), Credit Cards (CC), Debit Cards (DC).
Please visit http://azdhs.gov/vital-records/ or call for the most current fee schedule for each offi ce.
Gila County Health & Emergency
Navajo County Public Health
Management
Bureau of Vital Records
1818 W. Adams St.
Office of Vital Records
Services District
Phoenix, AZ 85007
5515 S. Apache Ave., Ste.100
117 E. Buff alo St.
(602) 364-1300
Globe, AZ 85501
Holbrook, AZ 86025
(928) 402-8811
(928) 524-4750
(C) (MO) (CC) (DC)
Mail to: PO Box 6018
(C) (PC) (MO) (CC) (DC)
(MO) (CC) (DC)
Phoenix, AZ 85005
Pima County Health Department
Certified Copies of Birth and Death
Graham County Health Department
Vital Records Offi ce
Certificates are Available by Mail Only
820 W. Main
3950 S. Country Club Road Ste. 100
Safford, AZ 85546
Apache County Public Health Services District
Tucson, AZ 85714
(928) 428-4441
110 East First Street South
(520) 724-7932
(C) (MO) (PC) (CC) (DC)
St. Johns, AZ 85936
(C) (MO) (CC) (DC)
(928) 337-7668
Greenlee County Health Department
Pinal County Health Department
(MO) (CC) (DC)
Office of Vital Registration
36235 N. Gantzel Rd.
Mail to: PO Box 697
253 5th St.
San Tan Valley, AZ 85142
St. Johns, AZ 85936
Clifton, AZ 85533
(520) 866-4670 / 1-800-231-8499
Mail to: PO Box 936
Cochise County Health and Social Services
(C) (MO) (CC) (DC)
Clifton, AZ 85533
Office of Vital Records
(928)865-2601
Pinal County Health Department
Sierra Vista Office
(C) (MO)
41600 West Smith-Enke Rd.
4115 E. Foothills Dr.
Bldg. 15
Sierra Vista, AZ 85635
Maricopa County
Maricopa, AZ 85138
(520) 803-3925 and
Office of Vital Registration
(520) 866-4621 / 1-800-231-8499
(520) 432-9406
Central Valley Office
(C) (MO) (CC) (DC)
(C) (MO) (CC) (DC)
3221 N. 16th St., Ste. 100
Phoenix, AZ 85016
Pinal County Health Department
Douglas Office
(602) 506-6805
Florence - Mail Only
1012 North G Ave. Ste.101
(C) (MO) (CC) (DC)
P.O. Box 2945
Douglas, AZ 85607
Florence, AZ 85132
(520) 805-5600
North Valley Office
(520) 866-7318 / 1-800-231-8499
(C) (MO) (CC) (DC)
2423 W. Dunlap Ave., Ste.110
(C) (MO) (CC) (DC)
Phoenix, AZ 85021
Bisbee Office
(602) 506-6805
Pinal County Health Department
1415 Melody Lane, Building A
(C) (MO) (CC) (DC)
1729 N. Trekell Rd., Ste.120
Bisbee, AZ 85603
Casa Grande, AZ 85122
(520) 432-9411
East Valley Office
(520) 866-7447 / 1-800-231-8499
(C) (MO) (CC) (DC)
331 E. Coury Ave.
(C) (MO) (CC) (DC)
Mesa, AZ 85210
Benson Office
(602) 506-6805
Yavapai County Health Department
126 W. 5th Street
(C) (MO) (CC) (DC)
1090 Commerce Dr.
Benson, AZ 85602
Prescott, AZ 86305
(520) 585-8200
West Valley Office
(928) 771-3125
(C) (MO) (CC) (DC)
1850 N. 95th Ave., Ste.182
(C) (MO) (PC) (CC/DC)
Phoenix, AZ 85037
Certified Copies of Birth Certificates and
Wilcox Office
(602) 506-6805
Death Certificates are Available by Mail Only
450 S. Haskell Ave.
(C) (MO) (CC) (DC)
Wilcox, AZ 85643
For all Mail: PO Box 2111
Yuma County Health Services
(520) 384-7100
Phoenix, AZ 85001
Vital Records Department
(C) (MO) (CC) (DC)
2200 W. 28th St.
All sites offer same day service
Mohave County Public Health
Yuma, AZ 85364
Please send any mail requests to the Sierra Vista or
County Administration Building Drop Box in
(928) 317-4530
Bisbee locations only.
lobby 700 W. Beale St.
(C) (MO)
Kingman, AZ 86401
Coconino County Health and Human Services
Mail to: PO Box 7000
Vital Records
Kingman, AZ 86402
2625 N. King St.
(928) 753-0748
Flagstaff, AZ 86004
(C) (MO) (CC) (DC)
(928) 679-7272
Certified copies of Birth Certificates are Available
(C) (MO) (PC) (CC)
by Mail Only or Drop Box
PARTICIPATING OFFICE LOCATION (02/20)
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