Fillable Printable Vital Records Request for Copy of Birth Certificate - Arizona
Fillable Printable Vital Records Request for Copy of Birth Certificate - Arizona
Vital Records Request for Copy of Birth Certificate - Arizona
Arizona Vital Records Request for Copy of Birth Certicate
Please visit the State Office of Vital Records website www.azhealth.gov for
the following information:
• Fees
• Locations, office hours, and availability of services
• Eligibility requirements and acceptable identification
• Correction, amendment, and registration information
• Download forms
Telephone: 602-364-1300
Apply Online: www.VITALCHEK.com
(Refer to website for their current fees)
CUSTOMER ChECkliST
2 Clear photocopy of the front and back of your valid, signed
government photo ID OR have your signature notarized
2 Proof of relationship enclosed if required (birth certificates,
certified court documents, etc)
2 Sign the application
2 Include self-addressed stamped envelope
2 Correct fee enclosed
PAYMENT iNFOBiRTh CERTiFiCATE iNFORMATiONPERSON REQUESTiNGNOTARY AREA
Today's Date
Applicant's Full Name—Printed
First Middle last
Applicant's Signature—Required
Date of Birth
Date of Birth
Date of Birth
State (if US) or Country of birth
State (if US) or Country of birth
Town/City of Birth
Mother's/Parent's First Name
Father's/Parent's First Name
Middle
Middle
Last Name prior to rst marriage
last
County hospital
Name on Birth Certicate
First Middle last
Mailing Address
Street City State Zip
# of Certied Copies Requested Purpose of Request Payment Method
Sex
2 Male 2 Female
Do you belong to an Arizona Tribe?
2 Yes 2 No
if yes, please specify tribe.
Daytime Telephone Number Email Address
Your Relationship to Person on Certicate—Check One *PROOF of relationship MUST be provided if you are NOT named on the certicate.
2 Parent 2 Self 2 Brother/Sister 2 Grandparent 2 Legal Guardian 2 Spouse 2 Gov't Agency 2 Other
State of County of
On this day of , 20 before me personally appeared
(name of signer), whose identity was proven to me
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
Afx Seal/Stamp Here
Payment information
Card Number _______ - _______ - _______ - _______ Card Expiration Date / 2 Visa 2 MC
Signature of Cardholder— Must provide photocopy of valid government issued identication if cardholder is not the applicant. Amount to be Charged
$
For Ofce Use Only—State File Number/Serial Number
VS-11 (05/15)
Request iD
iNFO
PARTICIPATI NG OFFICE LOCATIONS (06/15)
PARTICIPATING OFFICE LOCATIONS
The State Office of Vital Records does not provide walk-in service for birth and death certificate issuance. Services available at
the State Office of Vital Records by appointment only are delayed birth registration, adoptions, foreign born, putative father, and
amendment s and corrections for births that occurred prior to 1997 and deaths th at occurred prior to 2008.
For walk-in customer service, please visit your nearest local county vital records office providing walk-in service as listed below.
Please note payment types accepted at various office 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 office.
State Office of Vital Records
1818 W. Adams St.
Phoenix, AZ 85007
(602) 364-13 00
(C) (MO) (CC)
Mail to: PO Box 6018
Phoenix, AZ 85005
Certified Copies of Birth and Death
Certificates are Available by Mail Onl y
Apache County Public Health Services District
75 W. Cleveland St.
Johns, AZ 85936
(928) 337-76 68
(MO) (C)
Mail to: PO Box 697
St. Johns, AZ 85936
Cochise County Health Department
4001 E. Foothills Dr.
Sierra Vista, AZ. 85635
(520) 803-39 25
(C) (MO) (DC)
Coconino County Health Departme nt
2625 N. King St.
Flagstaff, AZ 86004
(928) 679-72 72
(C) (MO) (PC) (CC)
Gila County Health & Emergency Services
Office of Vital Records
5515 S Apache Ave., Ste. 100
Globe, AZ 8550
1
(928) 402-88 11
(C) (PC) (MO)
Graham County Health Department
820 W. Main
Safford, AZ 85546
(928) 428-44 41
(C) (MO) (PC)
Greenlee County Health D ep artment
Office of Vital Registration
253 5th St.
Clifton, AZ 85533
(928) 865-26 01
(C), (MO)
Mail to: PO Box 936
Clifton, AZ 85533
La Paz County Vital Records Office
1112 Joshua Ave, Ste. 206
Parker, AZ 85344
(928) 669-11 00
(C) (MO)
Maricopa County
Office of Vital Registration
3221 N. 16th St., Ste. 100
Phoenix, AZ 85016
Office of Vital Registration
3003 W. Thomas Rd., Ste. 200B
Phoenix, AZ 85017
Office of Vital Registration
4419 E. Main St., Ste. 105
Mesa, AZ 85205
Office of Vital Registration
1850 N 95th Avenue, Ste. 182
Phoenix, AZ 85037
(602) 506-68 05 (C)
(MO) (CC)
For all Mail: P.O. Box 2111
Phoenix, AZ 85001
Mohave County Public health
County Administration Building Drop
Box in lobby:
700 W. Beale St.
Kingman, AZ 86401
Mail to: PO Box 7000
Kingman, AZ 86402
(928) 753-07 48 (C)
(MO)
Certified Copies of Birth Certificates are Available
by Mail Onl y or Drop Box
Navajo County H ea lth Department
117 E. Buffalo St.
Holbrook, AZ 86025
(928) 524-47 50
(MO)
Pima County Health Department
Vital Records Office
3950 S. Country Club Road Ste. 100
Tucson, AZ 85714
(520) 724-79 32
(C) (MO) (CC) (DC)
Pinal County Health Department
36235 N. Gantzel Rd.
San Tan Valley, AZ 85142 (520)
886-4670 / 1-800-231-8499 (C)
(MO) (CC)
Pinal County Health Department
41600 West Smith-Enke Rd.
Bldg. 15
Maricopa, AZ 85138
(520) 866-42 61 / 1-800-231-8499
(C) (MO) (CC)
Mail to: PO Box 2945
Florence, AZ 85132
(Funeral Homes Only)
Santa Cruz County Health Services
2150 N. Congress Dr. Ste. 115
Nogales, Arizona 85621
(520) 375-79 00
(C) (MO)
Yavapai County Health Department
1090 Commer c
e Dr.
Prescott, AZ 86305
(928) 771-31 25
(C) (MO) (PC) (CC/DC)
Certified Copies of Birth Certificates and Death
Certificates are Available by Mail Only
Yuma County Health Services
Vital Records Department
2200 W. 28th St.
Yuma, AZ 85364
(928) 317-45 30
(C) (MO)
