ARKANSAS…

                                                       ARKANSAS DEPARTMENT OF HEALTH
                                                           Vital Records Section-Slot 44
Date                                                              4815 West Markham Street
                                                                   Little Rock, AR 72205
                                                      BIRTH CERTIFICATE APPLICATION
    Only Arkansas births are recorded in this office. There are a limited number of birth records filed in this office prior to February 1, 1914. The fee is
    $12.00 for the first copy ordered and $10.00 for each additional copy of the same record. The fee must accompany the application. Send check or
    money order payable to the Arkansas Department of Health. DO NOT SEND CASH. Of the total fee you send, $12.00 will be kept to cover search
    charges if no record of the birth is found. Only the names and dates listed will be searched for the $12.00 fee. Names and other dates submitted later
    will require an additional $12.00 non-refundable fee. Mail this application and the money to the address above. Please allow 4-6 weeks for delivery.

    List Below All Possible Birth dates and Names Under Which the Certificate May be Registered                              (Type or Print)
                             First Name                      Middle Name                                                   Last Name
1     Full Name at
      Birth
                             Month                                Day                    Year                     Sex         Race        Age Last Birthday
2     Date of Birth

                             City or Town                                   County                             State                      Order Of This Birth
                                                                                                                                          (1st, 2nd, 3rd, etc.)
3.     Place of Birth
                             Name of Hospital or Street Address                                                            Name of Attendant at Birth


                             First Name                           Middle Name                                              Last Name
4.     Full Name of
       Father
5. Full Maiden Name          First Name                           Middle Name                                              Last Name
  of Mother (Name
  Before Marriage)
      If this child has been adopted, please give original name if known.
                                                                                                                        DO NOT WRITE IN THIS SPACE
                                                                                                            Name of Searcher
      If you have received a copy before, please give certificate number.
      If this is a delayed certificate, when was it filed?
      What is your relationship to the person whose certificate is being requested?                         Index


      What is your reason for requesting this certificate?                                                  Delayed                            Prior

                                                                                                            Volume Number
      Is the person whose certificate is being requested still living?  Yes               No
      Signature and telephone number of person requesting this certificate.                                 Page Number                      Year


Certificates may also be ordered by the following methods:
Internet: www.expressvitalrecords.com or www.vitalchek.com. The service fee and the
certificate fee are charged to your debit or credit card. (Visa, Master Card, Discover or                   Copy (s)
American Express). Overnight shipping is available for an additional fee.
                                                                                                            CARD(S)*           *Not valid for federal or
                                                OR
                                                                                                            state identification purposes.
Telephone: Toll free (888) 803-1118 or (866) 209-9482. The service fee and the certificate
fee are charged to your debit or credit card. (Visa, Master Card, Discover or American
Express). Overnight shipping is available for an additional fee.                                                         HOW MANY
                                                                                                            1st copy or card costs $12.00
                                                 OR                                                         Each additional copy or card costs $10.00

Walk-in: You may order a certified copy of the birth record by coming into this office. Orders              AMOUNT OF MONEY ENCLOSED $
are accepted for same day issuance from 8:00 A.M. until 4:00 P.M. Monday through Friday.
The office is located at 4815 West Markham St. Little Rock, AR 72205. Please order family
history and genealogy by mail or internet


Please PRINT below the name and address of the
person who is to receive this request.


                                                                              Any person who willfully and knowingly makes any false statement in an application for a
                                                                             certified copy of a vital record filed in this state is subject to a fine of not more than ten
                                                                             thousand dollars ($10,000) or imprisoned not more than five (5) years, or both
                                                                             (Arkansas Statutes 20-18-105).


VR-7 (R8/07)