Benelux Exchange
Birth or Baptismal Certificate Submission

Please submit all information exactly as it appears on the Birth Certificate or record. Click the Submit button below when finished.

If you are unable to use this form, please email me the information listed below.

Your Email:			e.g.: [email protected]
Last Name:			e.g.: Doe
First Name:			e.g.: John
Date of Birth:			e.g.: 2019-06-18 (for June 18, 2019)
Town of Birth:			e.g.: Deurne
County of Birth:			e.g.: Antwerpen
Country of Birth:
Are you willing to make the certificate available to others?