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BDM93B
Request for 
New Zealand Birth Certifi cate or Printout
He tono mō tētahi Tiwhikete Whānautanga o Aotearoa, Tānga rānei
You may be able to order your certifi cate and/or printout by phoning us
 Freephone 0800 22 77 77 (+64 4 463 9362 if outside New Zealand)
Do NOT use this form if your baby has not already been registered.  If you have not registered your baby 
go to www.govt.nz/birth-registration where you will also be able to order a certifi cate.
Step 1
The birth certifi cate/printout I want (Fields with * must be completed)
Surname*
First names*
Place of birth (town or city) 
Date of birth*
D D
M M
Y Y Y Y
Parent 1 full name
Parent 2 full name
Parent 1 full name at birth, if different from above
Parent 2 full name at birth, if different from above
Other information 
(e.g. folio number)
Step 2
Delivery Address 
If a standard certifi cate is ordered, it will be folded and the 
If ordering certifi cates and printouts: the certifi cate will 
delivery name and address will appear on the back
be posted to you and the printout will be emailed
Delivery name
Flat number (if applicable)
Street number
Street   
Suburb or rural locality
City, town or district
Postcode
Country (if not New Zealand)
Your daytime phone number 
Your email address (If ordering a Printout we will email it to you)
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Step 3
Certifi cates*
*Defi nitions 
Standard 
Standard 
Standard
Forest
Beach
& Forest
& Beach
A certifi cate is an offi cial document containing 
registered information.
$39.80  $39.80  $26.50  $26.50  $26.50 
per set
per set
each
each
each
Quantity
Quantity
Quantity
Quantity
Quantity
Printouts*
A printout is a copy of the information from the 
registration and is not a legal document. Printouts 
are usually used for genealogical information 
purposes. A printout is either typed or a copy of 
the handwritten entry. Whether a typed or copy 
1874 and before $26.50 each
Quantity
of the handwritten entry is issued depends on the 
1875 and after $20.40 each
record - this is not an option.
Courier fee (optional):
To a New Zealand address add $5.00
To an overseas address contact us for details
If you intend to use the certifi cate overseas refer to www.dia.govt.nz/Document-authentication
Payment details
DO NOT POST CASH
Total amount to pay  $
I enclose a New Zealand cheque, New Zealand money order 
or International bankdraft in New Zealand dollars made out 
to: The Department of Internal Affairs
Charge my credit/debit card (Do not post your card):
VISA
Mastercard
Amex
Prezzy Card
Card number
Expiry date
Cardholder’s name
Cardholder’s signature
• If paying in person at our Auckland, Manukau, Wellington or Christchurch offi ce we also accept EFTPOS and cash payments.
• If the record cannot be found we will contact you and search fees will apply.
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 Freephone 0800 22 77 77
Phone +64 4 463 9362 (if outside New Zealand)
Warning It is an offence, punishable by imprisonment and/or a fi ne of up to $10,000, to make a false statement to obtain a certifi cate, printout or a 
source document, or to provide any means of identifi cation knowing that it is false or is suspected to be forged or falsifi ed.
Steps 4 and 5 must be completed unless you are requesting a certifi cate/printout of a birth that occurred 
more than 100 years ago, or of a still-birth (this means the baby was not alive at birth) that occurred more than 50 years ago   
Step 4
My declaration (the person ordering the certifi cate/printout must complete)
My Details
Surname
First names
Surname at birth (if different from above)
First names at birth (if different from above)
Place of birth (town or city) including country if not New Zealand   
Date of birth
D D
M M
Y Y Y Y
I declare that the information about me that is entered on this form is true and correct
Signature
Date signed
D D
M M
Y Y Y Y
If ordering on behalf of a company state their name below and include an original signed request on letterhead
Your details or the company name will be entered in the Access Register. For information about the Access Register visit www.bdm.govt.nz
Step 5
Referee’s declaration (must be completed by another person who is 16 years of age or older)
I have known the orderer for at least 6 months or have seen a government issued photo
identifi cation of the orderer and I am 16 years of age or older – I am satisfi ed the information about 
the orderer’s identity stated in this form is true and correct
Signature of referee
Date signed
D D
M M
Y Y Y Y
Full name of referee
Phone number of referee 
Contact address of referee
Step 6
Before posting make sure Step 5 is completed by any other person 16 years of age or older (even if you are ordering 
your own or a family members certifi cate)
    Post with fee to: 
Privacy Statement The information on this form is collected under 
Certifi cate Team
the Births, Deaths, Marriages, and Relationships Registration Act 1995. As 
Births, Deaths, Marriages and Citizenship
part of processing your request, your identifi cation details will be checked 
PO Box 10526
against other records held by Births, Deaths, Marriages and Citizenship or 
other government agencies, as authorised by law.
Wellington 6143
New Zealand
Last updated 9 August 2016
Offi ce Use Only                                                                                                  
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