ORDER FORM FOR BIRTHS, DEATHS, MARRIAGES
		========================================

-INFO. ON PERSON ORDERING: **ALL FIELDS ARE REQUIRED**

Your Name:		_________________________________________

Your Address:		_________________________________________

			_________________________________________

Your City:		_________________________________________

Your State/Zip:		_________________________________________

Your E-Mail:		_________________________________________

Your Phone(OPTIONAL):	_________________________________________


-INFO. ON CERTIFICATE HOLDER: **ENTER AVAILABLE INFORMATION**

Certificate Holder's Last Name:		_________________________

Certificate Holder's First Name:	_________________________

Certificate Holder's Middle Name:	_________________________

Bride's Last Name (if applicable): 	________________________

Bride's First Name (if applicable):     _________________________


State and County of Occurrence:		_________________________


Date of Occurrence:			_________________________


-FOR BIRTH CERTIFICATES ONLY: **ENTER ALL AVAILABLE INFORMATION**


Certificate Holder's Mother's Maiden Name:	_________________

Has Certificate Holder ever been involved
	 in an Adoption or Legal Name Change:	()yes	()no



Payment Enclosed:	$44.95 plus
			()$29.95-Special Delivery (if applies)
			=========================================
	
You will be notified within two weeks with delivery information.
Mail to:

The Vitalsearch Company Worldwide, Inc.
Payment Processing
4000 Pimlico Drive
Suite 114-143
Pleasanton, CA. 94588-3485