Please fill out the form below and print it. Then, make a copy of your
driver's license or your state issued identification card (if applicable)
and fax both to (713) 874-1245. You MUST have a Visa or Mastercard
number on the below. We cannot obtain birth certificates for
Conneticut, Hawaii, or Louisiana.

NOTE:
Texas Tower can process your passport along with your birth certificate.
Your total service fee for both is $150.00. Choose yes at the bottom
of the order if you wish to exercise this option.

There are additional steps necessary to complete your passport.
Please review our passport section and follow the procedures that
apply to you.

PLEASE USE CAPITAL LETTERS ON THE BELOW
No Debit Cards
(includes Visa/Mastercard Check Cards that take funds from a checking account)

 FEES: State Fee: $25.00-$35.00 Plus Our Fee: $45.00

Certified Birth Certificate Request

Credit Card Number: Expires:
Certificate Holder's Name at Birth:

(first)(middle)(last)
Father's Name:

(first)(middle)(last)
Mother's Full Maiden Name:

(first)(middle)(last)
Birth Date: State of Birth (choose one):
Adopted: County: City:
Hospital: Sex: Number of Copies:
Ship Method: Express Courier Date of Departure:
Ship to Name:
Ship to Address:
City: State: Zip:
Daytime: Telephone # -
Signature: ___________________________ Date:
I authorize Texas Tower to obtain my birth certificate for me.
I understand that Texas Tower is not reponsible for any service
pered by any overnight courier service.
Please charge me "total service fee $150.00" for passort and birth
certificate processing

All Sales Final
No Debit Cards

YOU MUST ALSO FAX A COPY OF YOUR DRIVERS LICENSE
(if available)

our fax number: (713) 874-1245
our address:
2020 Montrose Blvd. Suite 400
Houston, TX 77006

PLEASE SIGN THIS DOCUMENT BEFORE FAXING