ABOUT TRUST ONLINE
US Birth Certificate.Com Order Form

ABOUT TRUST ONLINE
You will need to fill out the form below and hit the print button on your browser. Then make a copy of your driver’s license or your state issued identification card and fax both to us at 713-629-0396 or 713-785-1458. You will get an emailed sales receipt from our office, your order will start processing immediately and if there is a problem with your order we will call you. Your birth certificate will be delivered by an overnight courier service, average delivery times are listed on the previous page. We cannot obtain birth certificates for Connecticut, Iowa, New Mexico or Hawaii.
PLEASE USE CAPITAL LETTERS ON THE FORM BELOW
Fees: State Fee: $22-$69 (Most are $35-$40) Plus Our Fee: $49
Please charge me "total USBC.com service fee $170" for passport & birth certificate processing
Emergency Birth Certificate Processing (additional fee $25.00)
Lifetime birth certificate & passport processing additional $99 (government/state fees excluded)
Certified Birth Certificate Request
Credit Card Number: Expires
Person's Name on Credit Card: CVC- Code ( Required)
Credit Card Billing Address:
CityState Zip
Certificate Holders Name at Birth ( or adopted name)
:

(First)(Middle)(Last)
Fathers Name:

(First)(Middle)(Last)
Mother’s Full Maiden Name: Maiden Last Name

(First) (Middle)(Last)
Certificate holders Birth Date
State of Birth   Reason for Request:
County of Birth City of birth
Adopted or Legal Name Change excluding marriage
If adopted use adopted name and adopted parents names, Pre-adopted certificates are unavailable.
Hospital: Sex:     Number of Copies


Ship Method:
Ship to Name:
Ship to Address:***( No P.O. Boxes )
CityState Zip
Daytime Telephone #  () -  - Extension:
Alternate Telephone #  () -  - Extension:
Email:
(REQUIRED)
What kind of device did you make your order on?:
Certificate Holders Signature:___________________________ Date
Credit Card Holder's Signature:___________________________ Date

I authorize USBirthcertificate.Com to be my legal representative and to obtain or order my birth certificate for me.
USB.com will charge your credit card our fee upon receiving your request even if the information is incomplete,
the state of birth will charge your credit card seperately in some cases. Please contact us if the certificate does not arrive by the
stated process time. The lifetime birth certificate & passport processing service fee is non refundable and can only  be used for the person named on the birth certificate request. There are no refunds of USBirthcertificate.com's
services fees for any reason. I understand Usbirthcertificate.com is a private expediting service and I am hiring
them to expedite my birth certificate order. I understand there is a state fee and Usbirthcertificate.com's fee. By signing the form above you agree to these terms.
Our voice number is 888-629-2016. All Sales Final

** State Fees may appear on your credit card asVCN NETWORK, or VCN then the state name or as Bureau of Vital Statistics
***You must list a physical street address (No APO's , FPO's or PO Boxes) where someone can sign for the certificate
Someone must be available to sign for the Federal Express. If no one is there, Fedex will leave a note on the door (with a tracking number) to let you know that they have tried to deliver your package. You will need to follow the instructions on the door tag to coordinate delivery of your package.
Please lighten and enlarge the copy of your drivers license before faxing. No scanned images please.
If you have ordered the passport package please read and follow the instructions on our passport
section to be able to complete your passport application once your birth certificate arrives in your hands.
Please contact us if the certificate does not arrive by the stated process time.
We can not process this request without a signature.
Please sign before faxing.
Your privacy is important to us.Click here to read our privacy statement.
If you do not have access to a fax machine or would prefer to mail this order form to our office, please use the address below. If you mail this form and are paying with a money order please call our office so we can inform you of the total for your order.
Usbirthcertificate.com
Attn: Mail in Dept.
2600 South Gessner Rd. Ste 200
Houston, Texas 77063