| P
ALLANTE CENTER for ITALIAN RESEARCH |
Birth Record (Form A)
Use this form to request a certificate (genelogical extract) of an Italian birth
record, which will be
forwarded from
Italy. Use this form only
when you know the name, date and place.
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Typically on official town letterhead, and/or stamped with an official town seal. If you prefer a photocopy
of the original document (as created at the time of the event (eg. 1800s) in Italian, and often handwritten),
submit Form D.
You may request both (photocopy of original, and certificate) by submitting both Form A and Form D. Separate fee
for each. Please sign: I understand that I am paying a nonrefundable fee to "request a search" and there is no guarantee that the document(s) requested will be found. (Occasionally the document requested may not exist.) __________________________________ |
Ancestor's Date of Birth: Day____Month_________Year______
Name of Your Ancestor's Father: ___________________________
Source of your date information:
______________________________________________________
After 8 wks, if the search is "negative" or no response from Italy, you may
submit a new request with a new dates,name variation, or town.
Personal Check: payable to "Pallante Center", or use Paypal.com
Please Print Clearly: Our sucessful rate is high, if the info you provide is correct,
and if the birth was recorded in the registry book of the town).
Place of Birth (town):_______________________________________ in Province:________________________
*If you do not know the name of the town must use Form B.
Name of Ancestor:
(first) _______________________________________ (surname) ____________________________________
Male ___Female ___ If female, what was her surname at birth:____________________________________
*If you are unsure of the exact date, choose a three-year range to be searched. (From:______ To:______)
Name of Your Ancestor's Mother: ___________________________(Mother's surname at birth)_________________
*If you do not know the exact date, must know names of both parents
(including maiden name of mother).
(Is it from specific documents you’ve found, family stories, or a calculated
guess?)
WHERE SHOULD WE SEND THE RESULTS OF THE SEARCH? (Please print neatly)
Name: ____________________________
Address: _________________________________
Postal Code: ____________Country: ______________
Email: ___________________________________
THANK YOU FOR YOUR ORDER. **Please enclose a self-addressed, stamped envelope .
PAYMENT METHODS: Credit Card (USA residents only): VISA, Mastercard, American Express, Discover. (Print Clearly !)
Expiration date: (Month & Year) ____/____ . Security code __ __ __ __
Account Number: __ __ __ __ - __ __ __ __ - __ __ __ __ - __ __ __ __
Name on card: __________________________________Authorizing Signatue: ______________________________________