Certified Birth Certificate
Credit Card Number: Expires: Choose one:
Certificate Holder's Name at Birth (or adopted 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
Ship Method: Express Courier Date of Departure:
Ship-To Address (no P.O. Boxes)
City: State: Zip:
Daytime Telephone: ( ) - - - Extension
Alternative Telephone Number:( ) - -
I authorize Texas Tower to obtain my birth certificate for me.
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
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