California Birth Certificate Application Form

Birth information of the person on record

Please complete the birth information below as shown on the birth record. If you are applying on behalf of someone else (i.e. your child), please enter their birth information here.

State of birth

City of birth *

County of birth

Date of birth

Month *

Day *

Year *

Full name of the person on record

Please enter Full name at birth of the person on record as shown on the Birth Certificate.

First Name *

Middle Name

Last Name *

Suffix

Male Female

Yes No

Your relationship with person on record

Mother/Parent’s full name

Please enter the Mother/Parent’s full name as shown on Birth Certificate of the person on record.

First name *

Middle name

Father/Parent’s full name

Please enter the Father/Parent’s full name as shown on Birth Certificate of the person on record.

First name

Middle name

Last name

Suffix

Contact information

Please enter your full name as shown on your ID and your contact information.

First Name *

Middle Name

Last name *

Phone number *

Delivery information

Please enter the physical address where you want the certificate to be delivered.

City *

State *

Zip code *

I have read and understood the Terms and Conditions and Privacy Policy. *