Travisa Passport and Visa Services

Service Order Form: Birth Certificate

Please Note: This is not your visa application.

Complete all the fields with the needed information, and review the screen for accuracy.
Print the completed form and review your data to ensure the correct information has been entered.
Please fax the following documents to (312) 663-0835:
- Clear copy of your Driver License/State ID (Please enlarge for clarity).
- SIGNED Service Order Form (see below).
- Fees are payable by credit card ONLY (see below.) You will receive 2 separate charges, one for our service fee of $49.00 and one for State fees of $25.00 - $49.00 plus the Fedex fee.
- This process is done strictly by fax; you do not need to send us anything. Processing times are determined by the individual states (2-11 working days).

Birth Certificate Request
Date Needed:		Sex:
First Name:		Middle Name:	Last Name:
Mother's Maiden Name:
First Name:		Middle Name:	Last Name:
Father's Name:
First Name:		Middle Name:	Last Name:
Birth Information:
Hospital:		County:	City:
State:	For California requests only (You must fill out this form)
Certificate Holder Birthdate:		Year of Birth:
Has this certificate ever been changed or amended?

Customer Information:
Name:
Alternate Contact:
Company:
Address:	No P.O. Box
City:
State:		Zip:
Telephone:	( ) -
Fax:	( ) -
Email:

Shipping Information:
Same as previous:
Name:
Company:
Address:	No P.O. Box
City:
State:		Zip:
Telephone:	( ) -
Fax:	( ) -
Email:

Additional Comments and Information:

Fees and Payment:

Product	Fees	Total
Service Fee

Payment:
CCN:
Exp. Date:
I authorize Travisa to charge the TOTAL AMOUNT DUE to my credit card: I authorize Travisa to obtain my birth certificate: __________________________________________________ (signature)

State Fees $25.00 - $49.00 and Fedex shipping fee will be charged directly by the state.
Print and Sign this form and fax it with a copy of your drivers license or state ID to (312) 663-0835.
Only individuals listed on the certificate or a parent can request a birth certificate.
Payment Options:
Requirements and fees are subject to change without prior notice. All fees are non-refundable.
Requirements and fees are for U.S. Citizens only. Contact Travisa for information on other nationals.
Travisa Terms and Conditions

For passport instructions click here.

VPS

TRAVISA acts only as an agent, and accepts no responsibility for the services of any Travel Agent, Consulate, Passport Agency or Embassy in connection with the granting of visas, nor for any delays, loss of passports occasioned by such services or the U.S. Mail. Damage compensation is not available.

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