Birth Certificate Application Form - Mason County, Washington

This fillable "Birth Certificate Application Form" is a document issued by the Washington State Department of Social and Health Services specifically for Washington residents.

Download the PDF by clicking the link below and complete it directly in your browser or through the Adobe Desktop application.

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Birth Certificate Application
Full Name at Birth (First/Middle/Last):
Date of Birth (Month/Day/Year):
City or County of Birth (Washington State Only):
Father’s Full Name (First/Middle/Last):
Mother Full Maiden Name (First/Middle/Last):
REQUESTOR INFORMATION
Name of Requestor:
Phone Number:
Street/Mailing Address:
City / State:
Zip:
Signature of Requestor:
[ ] Pre-Order Pick Up between 4:00 & 4:30
[ ] Pre-Order Mail to above address
[ ] In-Person
($3 Expedite fee)
PAYMENT INFORMATION
PROCESSING FEES APPLY TO ALL PAYMENTS MADE BY DEBIT/CREDIT CARD IN THE AMOUNT OF $2.00 OR
2.5% WHICHEVER IS GREATER. We accept Cash, Check (made out to Mason County Treasurer), Visa, Mastercard,
Discover, American Express, & Debit
Number of Certificates:
_____ X $20.00
= $_______
(If paying by credit card, ADD $2.00 or 2.5% whichever is greater)
Expedite fee:
_____ X $3.00
Amount Paid:
[ ] Cash
[ ] Check (Payable to MCT)
[ ] Credit/Debit (processing fee)
$_________
APPLICATION SUBMITTAL
Applications may be submitted by:
Contact Information:
Mail or In-Person to:
Phone: (360) 427-9670 x400 Shelton
Mason County Public Health
(360) 275-4467 x400 Belfair
th
415 N. 6
Street, Shelton, WA 98584
(360) 482-5269 x400 Elma
Fax:
(360) 427-7787
FOR OFFICE USE ONLY
Date Picked up/Mailed: _________________________
Receipt #: ____________________________
Completed by: ________________________ Certificate #(s): ____________________________________________________
Birth Certificate Application
Full Name at Birth (First/Middle/Last):
Date of Birth (Month/Day/Year):
City or County of Birth (Washington State Only):
Father’s Full Name (First/Middle/Last):
Mother Full Maiden Name (First/Middle/Last):
REQUESTOR INFORMATION
Name of Requestor:
Phone Number:
Street/Mailing Address:
City / State:
Zip:
Signature of Requestor:
[ ] Pre-Order Pick Up between 4:00 & 4:30
[ ] Pre-Order Mail to above address
[ ] In-Person
($3 Expedite fee)
PAYMENT INFORMATION
PROCESSING FEES APPLY TO ALL PAYMENTS MADE BY DEBIT/CREDIT CARD IN THE AMOUNT OF $2.00 OR
2.5% WHICHEVER IS GREATER. We accept Cash, Check (made out to Mason County Treasurer), Visa, Mastercard,
Discover, American Express, & Debit
Number of Certificates:
_____ X $20.00
= $_______
(If paying by credit card, ADD $2.00 or 2.5% whichever is greater)
Expedite fee:
_____ X $3.00
Amount Paid:
[ ] Cash
[ ] Check (Payable to MCT)
[ ] Credit/Debit (processing fee)
$_________
APPLICATION SUBMITTAL
Applications may be submitted by:
Contact Information:
Mail or In-Person to:
Phone: (360) 427-9670 x400 Shelton
Mason County Public Health
(360) 275-4467 x400 Belfair
th
415 N. 6
Street, Shelton, WA 98584
(360) 482-5269 x400 Elma
Fax:
(360) 427-7787
FOR OFFICE USE ONLY
Date Picked up/Mailed: _________________________
Receipt #: ____________________________
Completed by: ________________________ Certificate #(s): ____________________________________________________

Download Birth Certificate Application Form - Mason County, Washington

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