www.justice.qld.gov.au

Proof of identity is required with submission of this form. Please read the requirements on page 3. Please print clearly using BLOCK LETTERS.

1. Priority (Onlyavailableifbirthisalreadyregistered)

Urgent (attractsadditionalfee–visitwww.justice.qld.gov.au/bdmfortimeframesandfees)

Non-urgent (noadditionalfee)

2. Type of record (Tickoption)

Certified copy

Short extract and/or

Commemorative package(Indicatewhichtype) Includes full official certificate

Queenslander

Welcome

Snake

Colonial

FirstTouch

Dugong

Legend

Hunting

Modern

Turtle

Visit www.justice.qld.gov.au/bdm to view fees and commemorative designs.

3. Applicant’s details (Proofofidentityrequiredrefertopage3)

Your relationship to the person named on the certificate (Tickoption)

Yourself

Brother/Sister

Parent

Grandparent/Grandchild

Son/Daughter

Husband/Wife

*Other(Pleasestate)_____________________________________________________________

* You will need to obtain written authority and proof of identification from the person named on the certificate to submit with this form. Written authority is a hand-written or typed letter that is signed by the person providing authority for you to obtain a copy of their certificate.

For proof of identification required from the person, refer to page 3 ‘Proof of identity requirements’. Essentially, you will need one form of identity from List 1 from the person, OR two forms of identity from List 2 and one form of identity from List 3 from the person in order to obtain a copy of their certificate.

Reason certificate is required

First names

Surname

Signature of applicant

Current residential address(Street,suburb,stateandcountry) Postcode

Date of application DD / MM / YYYYTelephone Daytimenumber Afterhoursnumber

Mobilenumber Email

Birth certificate/extract application

Births, Deaths and Marriages Registration Act 2003

Office use onlyEntrynumber

Datecopyproduced

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4. Postal details (Printnameandpostaladdressofpersontowhomthecertificate/sistobeposted)

First names Mr/Mrs/Dr/Ms/Miss

Surname

Postal address(Includestateandcountry)

Postcode

Type of post (Tickoneoption)

Regularpost(nocharge) Expresspost Registeredpost

International post Internationalregisteredpost

5. Birth details

Surname

First names

Date of birthIfdateunknown,periodtobesearched(searchfeesmayapply)

DD / MM / YYYY Present age

from DD / MM / YYYY to DD / MM / YYYY

Place of birth(mustbebornoradoptedinQueensland)

Mother’s first names

Mother’s maiden surname

Father’s first names

Father’s surname

6. Payment details

a)Ihaveenclosedacheque or money orderpayabletotheRegistryofBirths,DeathsandMarriagesfor $

or

b)Debitmycredit card* $ MasterCard Visa Expiry MM / YY

Card number / / /

Name of bank/credit union

Name on card

Signature ofcardholder

Please note all prices are subject to change. Applications will be kept on file for 12 months. If no action has been taken by the applicant within that time to address requests from the registry, it will be presumed that the application is no longer required.

* Credit cards may not be accepted at courthouses and cannot be used over the telephone. The registry reserves the right to contact applicants where credit card details are incorrect or incomplete.

7. Submission options

Post to RegistryofBirths,DeathsandMarriagesPOBox15188CityEastQld4002

Lodge at 110GeorgeStreet,BrisbaneoryourlocalQueenslandMagistratesCourtor QueenslandGovernmentAgencyProvider(QGAP).

For further information visit www.justice.qld.gov.au or phone 1300 366 430, international callers +61 7 3035 1000.

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Proof of identity requirements

Allapplicationsmustbeaccompaniedbyidentification(exceptiftherecordishistorical)andpayment.

TheRegistryofBirths,DeathsandMarriageswillsupplyacopyofabirthcertificatetoappropriatepeopleonrequest.(RefertoCertificateAccessPolicy)

Ifyouareapplyingforyourown certificateoracertificatefor your child(undertheageof18years),threeformsofidentificationforyourselffromTable1mustbesupplied.Photocopiesshouldbecertifiedbyaqualifiedwitness*asbeing“acorrectcopyofthedocument”.Youmustprovide:

• oneformofidentificationfromeachlist

• ifyouareunabletoprovideidentificationfromList1youmustprovidetwoformsofidentificationfromList2andoneformofidentificationfromList3.

Ifyouareapplyingon behalf of someone else(otherthanforyourchild),youmustprovide:

• writtenconsentorauthorityfromthatpersonorapersonauthorisedundertheregistry’sAccessPolicyforaccesstotheirrecords

• threeformsofidentificationforthatpersonaswellasyourselffromTable1—photocopiesshouldbecertifiedbyaqualifiedwitness*asbeing“acorrectcopyofthedocument”.

Supplycertified copies if mailingyourapplication.Ifapplying in personbringinoriginal documents.

Table 1: Proof of identity documentsList 1 List 2 List 3

CurrentAustralianphotodriver’slicence

CurrentAustralianpassport

Currentoverseaspassport,withcurrententrypermit

CurrentAustralianFirearmslicence

CurrentDefenceForceorPoliceServicephotoIDcard

Over18’sIDcard.

CurrentMedicarecard

Currentcreditcard,accountcardorpassbook

CurrententitlementcardissuedbytheCommonwealthGovernment

Currentstudentidentitycardorstatementofenrolment

Schoolorothereducationalreport,lessthantwelvemonthsold

CurrentdocumentofidentityissuedbythePassportOffice

Naturalisation/citizenship/immigrationpapersissuedbytheDepartmentofImmigrationandMulticulturaland IndigenousAffairs

Fullbirthcertificate

Securityguard/crowdcontrollicence

Taxfilestatement.

Utilityaccountlessthansixmonthsold(gas,electricity,homephone,etc)withcurrentresidentialaddress

Bankstatementwithcurrentresidentialaddress

Rent/leaseagreement

Ratesnotice.

Otherformsofidentificationmaybeaccepted,subjecttotheopinionoftheRegistrar-General.

* Qualified witnessesThefollowingpeoplecancertifyphotocopiesofdocumentsasbeing“acorrectcopyofthedocument”:

• justiceofthepeace

• barrister/solicitor

• commissionerfordeclarations

• notarypublic.

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www.justice.qld.gov.au

For more information

For more information or help with completing this application:

• telephone1300 366 430, international callers +61 7 3035 1000

• emailbdm-mail@justice.qld.gov.au(applicationsandsupportingdocumentationcannotbeemailed)orvisitwww.justice.qld.gov.au

• writetotheRegistryofBirths,DeathsandMarriages, POBox15188, CITYEAST,QLD,4002

• visittheRegistryofBirths,DeathsandMarriagesat 110GeorgeSt,Brisbane,Queensland

or

visityourlocalQueenslandMagistratesCourtorQueenslandGovernmentAgencyProvider(QGAP).

Modern Welcome First Touch Colonial

Dugong–Billy Missi Hunting–Bibi Turtle–Dennis Snake–Dave

Commemorative certificates

Queenslander

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©TheStateofQueenslandDepartmentofJusticeandAttorney-General2008

CommemorativecertificatesareA3(42cmx30cm)size.Toviewtheminfullcolour,visitwww.justice.qld.gov.au/bdm.