Quantity First Certificate
Quantity Additional Copies
Full Name on Certificate
Please enter the first, middle, and last name as it appears in the certificate.
Date of Birth
In the space provided enter the date of birth.
City of Birth
Champaign County - Unknown
Please select City of Birth.
Mother/Co-Parent Maiden Name
Please enter the maiden name of Mother/Co-Parent, as it appears on the certificate.
Father/Co-Parent Birth Name
Please enter the birth name of the Father/Co-Parent, as it appears on the certificate.
Relationship to certificate holder
Please select the Relationship to the certificate holder.
If OTHER was entered above, please enter the relationship here.
Intended use of document
Please enter the reason for intended use of the document.
Please select a response
FedEx (requires next field)
USPS (no additional cost)
USPS Priority (Click next check box)
Pick up In Person
USPS Priority Shipping
FedEx - Cost
Click the ? to calculate shipping cost, then enter the amount.
FedEx - Shipping To
If you have requested FedEx shipping, please indicate whether the recipient is a business or residence.
Is the recipient a business or residence?
FedEx - Business Name
If you have selected that the FedEx recipient is a business, please enter the name of the business here.
Multiple Certificate Orders?
Click the ? for more information
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