TEXAS TOWER

Please fill out and then print the following form. Then, make a copy of your Driver's License or your state
issued identification card (if available) and fax both to:

(713) 874-1245



The box that says V-Code means the last three numbers on the back of your Visa/Mastercard in the
signature box.

Please type in all caps below.



Check here for which service is needed:

Regular
Rush
Super Rush

Certified Birth Certificate                                                  



Credit Card Number: Expires: Choose one:
Name on Credit Card: V-Code (required)

Credit Card Billing Address:
City State Zip


Certificate Holder's Name at Birth (or adopted name):


 Father's Name:

 Mother's Full Maiden Name:


 Birth Date: State of Birth
County of Birth: City of Birth:
Adopted or Legal Name Change
If adopted use adopted name and adopted parents' names, Pre-adopted certificates are unavailable
Hospital: Sex: Number of Copies:
Ship Method: Express Courier        Date of Departure:
Ship-To Name
Ship-To Address (no P.O. Boxes)
City: State: Zip:
Daytime Telephone: ( ) - - - Extension
Alternative Telephone Number:( ) - -
Email:

Signature:__________________________________________________ Date:
I authorize Texas Tower to obtain my birth certificate for me.
I understand that Texas Tower is not responsible for any service performed by any overnight courier service.

All Sales Final
** By signing this form I agree that there are no refunds by Texas Tower.

Please fax a copy of your driver's license (if available--for minors please fax a copy of the parents' license)

Please insert any special instructions below (if your shipping address is a business address, please insert this
address below).


If you will not be at your shipping address to sign for the overnight courier package when it arrives
then you will need to leave a signed letter on your door requesting that the package be left wherever
you specify.

 

International Shipping Address

Name:

Phone:

Street Address:

City:

State/Province:

Country:

Zip/Postal Code:

 


International Shipping:
Please leave the shiping address blank on the birth certificate order form. You will have an additional FexEx
shipping charge placed on the credit card listed above.

PLEASE FAX A COPY OF YOUR DRIVER'S LICENSE (IF AVAILABLE--FOR MINORS PLEASE FAX A COPY OF THE
PARENTS' LICENSE)
Please lighten and enlarge the copy of your driver's license before faxing. No scanned images please.

Before faxing, please sign.