Please read carefully then follow instructions on form for Novelty Birth Certificate: To order a Birth Certificate PRINT THIS PAGE on Your Printer First, fill in the Questions, Sign, and mail complete form with CASH or MONEY ORDER IN US DOLLARS, MONEY ORDER MUST BE PAYABLE ON A US BANK to D. Moore at P.O.Box 183 - Hillview, Kentucky 40129-0183 . Allow 5-10 working days for return. Don't forget to add cost of mailing if You want any special return mailing. THERE IS NO REFUNDS ONCE DELIVERED! I will send a draft to your e-mail address before mailing of finished product for you to view and approve, once oked it will be mail. NO REFUNDS! Important: PLEASE print or type where I may read it, there will be a charge for any certificate reworked due to errors caused by not being able to read the order form! •ORDER•FORM•BIRTH CERTIFICATE• Note: Please fill in the following information exactly as wanted printed on certificate! TO BE COMPLETED FOR BIRTH CERTIFICATE: 1. NAME OF CHILD ______________________________________________________________________ (MOTHER) 2. MOTHERS NAME __________________________________________________ AGE _____ RACE _______________ MAIDEN NAME ________________________________ PLACE OF BIRTH (STATE OR FOREIGN COUNTRY)__________________________________________ SOCIAL SECURITY NO. ______________________ RESIDENCE AT TIME OF BIRTH (STREET ADDRESS)______________________________ CITY OR TOWN ___________________________________ COUNTY OR TOWNSHIP_______________________ STATE_________________________ ZIP ___________ (FATHER) 3. FATHERS NAME ___________________________________________________ AGE _____ RACE _______________ PLACE OF BIRTH (STATE OR FOREIGN COUNTRY)______________________________ SOCIAL SECURITY NO. ______________________ RESIDENCE AT TIME OF BIRTH (STREET ADDRESS)______________________________ CITY OR TOWN ______________________ COUNTY OR TOWNSHIP_______________________ STATE_________________________ ZIP _____________ PRESENT OR LAST OCCUPATION ____________________________ KIND OF INDUSTRY OR BUSINESS ____________________________ (CHILD) 4. PLACE OF BIRTH COUNTRY _____________________________________________ 5. SEX OF CHILD _______________ 6. NAME OF HOSPITAL____________________________________________________________________________ 7. LOCATION OF HOSPITAL CITY_____________________________ STREET ADDRESS ___________________________________ COUNTY OR TOWNSHIP ____________________________ STATE ________________________ ZIP ________________ 8. DATE OF BIRTH mm/dd/yyyy ___________________________________________________ TIME OF BIRTH ____________ AM.- PM. 9. COLOR OF SEAL (DEFAULT BLACK LASER PRINTED NO EXTRA COST) MAY HAVE IN RAISED LETTERING OF GOLD, BLACK, AT ADDITIONAL COST OF $6.00. CHECK HERE _______ AND INDICATE COLOR BY USING BOLD LETTERING FOR COLOR HERE ________. IF YOU NEED MORE LINES FOR INFORMATION THAT YOU MIGHT WANT APPLIED TO ORDER THAT IS NOT LISTED ABOVE PLEASE ADD ON SEPARATE PAPER AND MAIL WITH ORDER INDICATING THIS INFORMATION: DECLARATION (to be read by ALL prospective clients and customers). If you intend to order a certificate, you are reminded to read and sign the following notice prior to posting any orders. In consideration of my order I hereby release and forever discharge Home School Diplomas, it's agents, instrumentalities, and representatives of all liabilities, claims, damages or costs which I may have against them arising out of, or in any way connected with my order and receipt of such certificate and/or any other product from Home School Diplomas. I understand this waiver includes claims based on negligence, action, or inaction of myself and of any other parties. By affixing my signature I hereby agree to release all persons affiliated with Home School Diplomas from all damages that may arise from fraudulent, misrepresentative, and illegal use of certificates and/or any product provided by Home School Diplomas. While every care is taken to ensure the accuracy and integrity of the information pertaining to products provided by Home School Diplomas, the parties involved in the design of this website take absolutely no responsibility whatsoever for any damages or liabilities arising out of the unlawful misuse of such products. Please note that orders NOT accompanied by the following completed form with the appropriate signatures and payment, including miscellaneous incidental mailing and handling costs in the form of U.S. Money Order or Cash will either be returned or result to delay of processing. I the undersigned understand and confirm that this certificate was made for me to my specification as a novelty item. I will not misrepresent it as an official document from said agency, state or otherwise in any fraudulent manner. With my signature I confirm and accept full responsibility for the contents of and for any use or misuse of this certificate or degree after receiving it. By signing below I agree with all the aforementioned conditions. Signature__________________________________DATE____/_____/ 20_____ WE RESERVE THE RIGHT TO REFUSE SERVICE TO ANYONE •MAILING INFORMATION• Within the USA Mail to: Name ___________________________________________________________ Address: Street and Number _____________________________________________________________ City: ___________________________________, State: _____________________Zip: ______________ E-Mail Address: (THIS E-MAIL ADDRESS WILL ONLY BE USED TO CONTACT YOU IF WE HAVE QUESTIONS REGARDING THIS ORDER, OTHER WISE WE WILL BE REQUIRED TO RETURN THE ORDER INCOMPLETE IF PROBLEMS ARISE) E-mail ____________________________________________@______________________ Outside the USA Mail to: Name_________________________________________________ 1st Address__________________________________________ 2nd Address_________________________________________ City/Town_______________________________ Zip/Country Code___________________ Country____________________________ Telephone ( _____ ) ____________________________ Fax ( _____ )_________________________ ** For Novelty purposes only:** EXPRESS MAILING PLEASE READ BELOW IMPORTANT! NOTE: Check appropriate box for mailing. Please state by placing a check mark if you wish to WAIVER SIGNATURE when receiving EXPRESS MAIL! _______ Yes I wish to WAIVER SIGNATURE on my return mail, **NOTE** you will have to sign for document if this box is not checked! PLEASE WAIVER SIGNATURE WHEN SENDING EXPRESS MAIL TO ME, IF NOT IT COULD DELAY YOUR ORDER AS MUCH AS THREE DAYS! Please add $20.00 for US Postal Express Mailing of 8.5 x 11 order within the USA. _____ Please add $6.00 for US Postal Priority Mailing within the USA. _____ Please add $5.00 for Plain Heavy Weight Kraft Envelope Mailing within the USA. _____ Please add $40.00 for Regular US Postal Service International Mail and handling. ______ Add $52.00 - $100.00 depending on country destination for US Postal Service International Express Mail and handling. ______ * NOTE * FedEx states that it no longer accepts P.O. Box address from sender or receiver THEREFORE FedEx IS NO LONGER AN OPTION! * NOTE * DHL states that it no longer accepts P.O. Box address from sender or receiver THEREFORE DHL IS NO LONGER AN OPTION! * NOTE * UPS states that it no longer accepts P.O. Box address from sender or receiver THEREFORE UPS IS NO LONGER AN OPTION! Provide phone number where you may be reached for delivery. Please include COUNTRY CODE, AREA CODE, and TELEPHONE NUMBER to assure prompt delivery. ______________________________. I assure you that this telephone information will only be used for this reason. BIRTH CERTIFICATE PRICES AS FOLLOWS: $60.00 PER CERTIFICATE: PLEASE LIST PAYMENT AMOUNTS ENCLOSED WITH ORDER BELOW: $ ________ COST OF CERTIFICATES _________ NUMBER OF CERTIFICATES THIS ORDER: $ ________ RAISED EMBOSSED SEAL $ ________ OTHER PAYMENT, PLEASE STATE ________________________________________: $ ________ SUB TOTAL AMOUNT ENCLOSE WITH ORDER: $ ________ SUB TOTAL AMOUNT MINUS 20% DISCOUNT FOR CASH PAYMENT ** DO NOT INCLUDE POSTAGE IN THIS DISCOUNT OR IF PAYMENT IS MADE WITH MONEY ORDER **THIS DISCOUNT IS FOR US CASH CURRENCY ONLY **!!! $________ NOW ADD POSTAGE COST TO THE SUB TOTAL ABOVE: $________ FULL AMOUNT ENCLOSED WITH THIS ORDER: NOTE: MULTIPLE ORDERS WILL BE MAIL TOGETHER IN ONE ENVELOPE UNLESS OTHERWISE SPECIFIED WHEN ORDERING YOU MAY NOW PAY USING PAYPAL AND YOUR CREDIT CARD: YOU WILL STILL NEED TO COMPLETE ORDER FORM AND SEND BY E-MAIL, LAND MAIL, OR FAX TO 1-502-955-6790 PLEASE PAY AMOUNT LISTED AS FULL AMOUNT ENCLOSED WITH ORDER AS LISTED ABOVE: ** NOTE ORDERS WILL ONLY BE SHIPPED TO CONFIRMED PAYPAL ADDRESS WHEN PAYING WITH PAYPAL!** LAST UP DATED: 01-27-2012 *** END OF APPLICATION FORM:***