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CITY OF BEDFORD VITAL STATISTICS 2000 FOREST RIDGE BEDFORD TX 76021-1895 817-952-2112 817-952-2397 fax Abstract Receipt No. Cash Check No. Money Order MC/Visa Expiration APPLICATION FOR CERTIFIED COPIES OF BIRTH CERTIFICATE PLEASE PRINT Control No. THE FOLLOWING ARE THE ONLY RECOGNIZED QUALIFIED APPLICANTS Full Record BIRTH Please check your relationship to person in 1 Self Sibling Parent Child Grandparent Legal Representative Stepparent Guardian Spouse Military Recruiter REQUESTED 1 CERTIFIED COPY X 23. 00 23. 00 EXTRA COPIES OF SAME RECORD X 23. 00 EXPEDITED SHIPPING Via Express Mail TOTAL ENCLOSED I ACCEPT THIS CERTIFIED COPY AS IS State/Registrar File Full Name On Birth Record Date Of Birth City Of Birth Full Name Of Father Full Maiden Name Of Mother 1. First Name Middle Name Last Name at Birth 2. Month Date 4. City or Town County State Last Name Year 3. Sex TEXAS 8. YOUR NAME 9. Phone 8 00am 5 00pm 10. MAILING ADDRESS STREET ADDRESS CITY STATE ZIP 11. YOUR RELATIONSHIP TO PERSON IN ITEM 1 12. PURPOSE FOR OBTAINING THIS RECORD WARNING THE PENALTY FOR KNOWINGLY MAKING A FALSE STATEMENT IN THIS FORM CAN BE 2-10 YEARS IN PRISON AND A FINE OF UP TO 10 000. HEALTH AND SAFETY CODE CHAPTER 195 SEC. 195. 003 SIGNATURE OF APPLICANT DATE IDENTIFICATION TYPE Driver s License I. D. Card etc* NUMBER Birth records are confidential for 75 years therefore issuance is restricted to qualified applicants. PLEASE ATTACH A PHOTOCOPY OF records all identifying information items 1-6 relationship item 11 and purpose item 12 be provided in order to issue the record. Fees are subject to change without notice. Call 817-952-2112 for fee verification* Office Use Only Issued by. 00 23. 00 EXTRA COPIES OF SAME RECORD X 23. 00 EXPEDITED SHIPPING Via Express Mail TOTAL ENCLOSED I ACCEPT THIS CERTIFIED COPY AS IS State/Registrar File Full Name On Birth Record Date Of Birth City Of Birth Full Name Of Father Full Maiden Name Of Mother 1. First Name Middle Name Last Name at Birth 2. Month Date 4. City or Town County State Last Name Year 3. First Name Middle Name Last Name at Birth 2. Month Date 4. City or Town County State Last Name Year 3. Sex TEXAS 8. YOUR NAME 9. Phone 8 00am 5 00pm 10. MAILING ADDRESS STREET ADDRESS CITY STATE ZIP 11. Sex TEXAS 8. YOUR NAME 9. Phone 8 00am 5 00pm 10. MAILING ADDRESS STREET ADDRESS CITY STATE ZIP 11. YOUR RELATIONSHIP TO PERSON IN ITEM 1 12. PURPOSE FOR OBTAINING THIS RECORD WARNING THE PENALTY FOR KNOWINGLY MAKING A FALSE STATEMENT IN THIS FORM CAN BE 2-10 YEARS IN PRISON AND A FINE OF UP TO 10 000. YOUR RELATIONSHIP TO PERSON IN ITEM 1 12. PURPOSE FOR OBTAINING THIS RECORD WARNING THE PENALTY FOR KNOWINGLY MAKING A FALSE STATEMENT IN THIS FORM CAN BE 2-10 YEARS IN PRISON AND A FINE OF UP TO 10 000. HEALTH AND SAFETY CODE CHAPTER 195 SEC. 195. 003 SIGNATURE OF APPLICANT DATE IDENTIFICATION TYPE Driver s License I. HEALTH AND SAFETY CODE CHAPTER 195 SEC. 195. 003 SIGNATURE OF APPLICANT DATE IDENTIFICATION TYPE Driver s License I. D. Card etc* NUMBER Birth records are confidential for 75 years therefore issuance is restricted to qualified applicants.