Customer Service Charleston

Application for Certified Copy of West Virginia Birth Certificate

Please complete on-line, print, sign, and mail as instructed below or print except where signature is required. The following pertains to information that would be found on the certificate being requested. Name of person on the certificate Date of Birth

First Middle Last Month/Day/Year

Mother’s Maiden Name

First Middle Last Sex:

Father’s Name

First Middle Last

Place of Birth

City County State

Hospital

Male Female

Requestor’s Relationship:

Parent/Grandparent Guardian or agent Child/Grandchild Certificate of my own birth Spouse Brother/Sister

Making false statements and misuse of vital records will result in criminal and civil penalties pursuant to WV Code §16-5-38.

Printed Name (Required)

Requesting copies at $12.00 per copy and enclosing $ . Signature (Required)

Please send check or money order. Please do not send cash. Make checks payable to: Vital Registration

Send copies to: Print your address below. Area Code Your daytime telephone number:

City State Zip E-Mail address

Submit form with check or money order to: Vital Registration Room 165

350 Capitol Street

Charleston, WV 25301-3701

Telephone: 304-***-****

Last Revised 1/9/09

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