Roba Test Results page

Printing Instructions

Depending on which browser you use, you can
normally click the three horizontal lines at the top right (hamburger icon), and choose “print.”
Then, you’ll get a printpreview. Choose the scale that best fits the page
(usually 100% should work for you.)

Consular Vital Record Search Request

Certificate Holder Name
NAME: {Cert Holder FirstName:120} {Cert Holder MiddleName:111} {Cert Holder LastName:122}

SUFFIX: {Holder’s Suffix:112}

GENDER: {Gender:11}

Certificate Holder Birth Information

DOB: {Certificate Holder\’s Birth Date:10}

COUNTRY: {Foreign Country of Birth:172}
CITY: {City of Birth (if known):14}
PROV./ST: {Birth Province (if known):183}

Other Certificate Holder Info
ADOPTED OR NAME CHANGE?: {Adopted or Legal Name Change?:12}
{Adopted First:173} {Adopted Middle:174} {Adopted Last:175}
FS-240 NO. (if available/known): {FS-240 No.:182}
PASSPORT NO. (if available/known): {Passport No.:123}

Mother’s Maiden Name / Birth Information
NAME: {Mother\’s First:191} {Mother\’s Middle:114} {Mother Maiden Last Name:124}
DOB: {Mother Date of birth:177}
BIRTH COUNTRY: {Mother\’s birth country:180}
BIRTH STATE (if U.S.): {Mother\’s Birth State:184}

Father’s Name / Birth Information
{Father\’s First Name:126} {Father\’s middle:116} {Father\’s Last:125}
SUFFIX: {Father\’s Suffix:117}
DOB: {Father Date of birth:176}
BIRTH COUNTRY: {Father\’s birth country:179}
BIRTH STATE (if U.S.): {Father\’s Birth State:185}

Requester’s Name:
{Your First Name:130} {Your middle:132} {Your Last:131}
SUFFIX: {Requester\’s Suffix:129}

Requester’s Shipping Address
STREET ADDRESS: {shipAddress:162}
CITY: {shipCity:160}
ST: {shipST:166}
ZIP: {shipZip:161}

Requester’s Contact
TEL. MAIN: {Daytime Phone:107}
2ND TEL: {Second Phone:109}
EMAIL: {Email:28}

No. of Copies Requested:
{No. of copies FS-240 at $50 each (Quantity):195.3}

Date _____________________

Notarized Signature



State of ________________________________________) County of ___________________________________)

on (insert date) ______________________before me, (insert name, title of officer) _______________________________________________________

notary public, personally appeared
(insert name of signer)_______________________________________________________ who provided to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.

Signature of Requester (only signed in front of notary)


I certify under PENALTY OF PERJURY under the laws of the
State of _________________________ that the foregoing paragraph is true and correct. WITNESS my hand and official seal.

Notary Signature

__________________________________________________________________ Commission Expires
______________________ (Affix seal within this box)


Only sign the notary portion in front of a notary

Summary of charges for this transaction:

No. copies ordered: {No. of copies FS-240 at $50 each (Quantity):195.3}

U.S. State Department FS-240 filing cost: $50 each copy service cost: $60.00
Two-way (round trip) FedEx transit fee: $80.00
Your total order cost: {Total cost for order:198}

Payment Method Chosen

I am paying by: {Payment Type:37}

Credit Card Type: {Credit Card Type:188}

Name as appears on card: {Name on Card:40}

Card Number: {Credit Card Number:35}{Amex Card Number:36}

Expiration: {Card Expiration:38}

V-Code: {CVV Number:199}{Amex CVV Number:200}

Billing Address (if different)

Address: {ccAddress:168}
City: {ccCity:169}
St: {ccST:170}
Zip: {ccZip:171}

With my signature below, I hereby authorize to charge my card for the total amount above
(“Your total order cost”):

Cardholder’s Signature: ______________________________________________________________

Agreement to terms

I authorize to expedite my Record of Birth Abroad birth certificate for me. I agree that I have read the order form completly and if the information provided is incorrect, insufficient, or the government agency has no record of the birth that there are no refunds of’s expedite services fee for any reason. I understand that is a private expediting service and I am hiring them to expedite my Record of Birth Abroad birth certificate order. Please note: We, at, don’t create, change or amend birth records. We only help you retrieve existing records more easily and quickly. ALL SALES ARE FINAL.
With my signature, I authorize to expedite my Record of Birth Abroad Birth Certificate.

Applicant’s Signature: ______________________________________________________________

See next page for special shipping and other instructions.


Instructions for overnight shipment


1) ) In front of a notary public , you will need to sign the “Consular Vital Record Search Request” page. ( It will be necessary to resize the form when printing in some cases don’t get the form notarized unless you have printed in correctly and the birth information and notary information are on the same page)

2) ONLY FOR THOSE USING A CREDIT CARD: On page 2 of the printout, the “Record of Birth
Abroad Worksheet,” fill in your credit card payment information, and sign
underneath (For this signature, it is not necessary to be in front of the notary).

3) Sign the agreement authorizing to
act on your behalf (not necessary to be in front of the notary), also on page 2.

4)Create a readable copy of your valid driver’s license or State ID card, and copy it zoomed at 200% so the information is readable. (It must be a valid unexpired ID if not order will be canceled.)

5) Enclose the two signed form pages 1 and 2,
along with the copy of Driver’s lic./ID. Include a Money Order or Cashier’s Check in an overnight envelope
if you are not using a credit card.

6) For quicker results send shipment by the preferred method of either FedEx using “Standard Overnight” or UPS using “UPS Next Day Air Saver” or you can use USPS using “No signature required method or
the slower regular mail.” ( Do not use the more expensive early day package methods.
We are not open earlier enough to receive it and it will cost you more and also just delay things or we
may not receive it at all!

*** Important notice regarding shipping using UPS or US Postal Service ***

UPS attempts one delivery and, if missed, the package will be left at a UPS Access point. If left at that location
we won’t travel the two hour round trip to retrieve the package and it will be returned to you. Due to this policy we don’t recommend shipping by UPS because we can’t guarantee that we won’t miss a delivery,
unless you use standard, not priority, one day delivery.

If you choose the United State Postal Service for
shipment, you can use the no signature required or regular mail option it will
be delivered to a locked and secure box at our location. Do not select the signature required option.
All signature required packages are delivered between 8-9 a.m. at our
location, and we aren’t open that early. The package will be returned to the post
office. We will not go to the post office to retrieve packages if you select the
signature required option.

Overnight Shipping Address
1143 N. Madison St., Lafayette, OR 97127
Tel. (800)856-2526 or (503) 714-4364

AFTER WE RECEIVE YOUR SHIPMENT: Within two business days of receiving your package, you’ll get an emailed sales receipt. When your order has begun to be processed by our office, that’s when your credit card will be charged (if one is used). To keep things moving, it’s important that we may easily contact you during our business hours in case we have any questions about your order. You’ve indicated the best numbers to reach you: Main Phone: {Daytime Phone:107} and Alt. Phone: {Second Phone:109}.

Thank you for your order!