Birth Certificate Application - Arkansas

ARKANSAS DEPARTMENT OF HEALTH
VITAL RECORDS, 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, a copy of your photo id 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)
1 Full Name at Birth
First Name
Middle Name
Last Name
2 Date of Birth
Month
Day
Year
Sex
Age Last Birthday
3. Place of Birth
City or Town
County
State
Name of Hospital or Street Address
4. Full Name of
Father
First Name
Middle Name
Last Name
5. Full Maiden Name
of Mother (Name
Before Marriage)
First Name
Middle Name
Last Name
If this child has been adopted, please give original name if known.
If this is a delayed certificate, when was it filed?
What is your relationship to the person whose certificate is being requested?
What is your reason for requesting this certificate?
Is the person whose certificate is being requested still living? Yes No
Signature and telephone number of person requesting this certificate
.
X
All requests for certificates require photo identification.
Certificates may also be ordered by the following methods:
Internet: www.vitalchek.com. All internet orders are expedited. 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 costs $12.00
Each additional copy costs $10.00
AMOUNT OF MONEY ENCLOSED $
OR
Telephone: Toll free (866) 209-9482. All telephone orders are expedited. 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.
OR
Walk-in: You may order a certified copy of the birth record by coming into this office. Orders
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 the name and address of the person
who is to receive this request on the line below.
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 (R 8/11)
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