Office of the Village Clerk
243 Main Street, Johnson City, New York 13790
(607) 798-7861
Name: (First, Middle, Last) _______________________________________________________
Date of Birth: ________________ Place of Birth: (Hospital or street address)____________________________
Village of Johnson City, Broome County, New York.Father: (First, Middle, Last)_______________________________________________________________
Mother's Maiden Name: (First, Middle, Last)________________________________________________
Number of copies requested ________________ (Fee: $10.00 per certificate or no record certification)
Purpose for which record is required: (check one) ___ Driver's license ___ Social Security
___ Retirement ___ Employment ___ Working Papers ___ School Entrance ___ Passport
___ Marriage License ___ Welfare Assistance ___ Veteran's Benefits ___ Court Proceeding
___ Entrance into Armed Forces ___ Other (specify) ___________________________________
Applicant Information
Name: (First, Middle, Last)________________________________________________________________
Telephone number: _________________ Social Security Number: _______________________
What is your relationship to person whose record is required? (check one)
___ Self ___ Parent ___ Other (specify) ____________________________________________
Signature of Applicant: __________________________________________ Date: ___________
Address of Applicant: (Street, City, State, Zip Code) ______________________________________
____________________________________________________________________________
If attorney, give name and relationship of your client to person whose record is required.
Name of Client: _____________________________ Relationship: ___________________________
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BELOW FOR REGISTRAR'S USE ONLY (Photocopy ID and attach to application form)
TYPE OF ID:
_____ Driver's License State: _____ Number: __________________________________
_____ Other ID, specify: _________________________ Number: ________________________
TYPES OF ACCEPTABLE IDENTIFICATION
Do Not Issue Copy Unless One of the Below Types of
Identification is Presented
1. Driver's License
2. Non-driver's license
3. Passport
4. Naturalization Papers
5. Military ID
6. Employer's Photo ID
7. Two utility bills, showing applicant's name and address
8. Police report of lost or stolen ID