Fax Order Form Minnesota Note: Fill out form only on a device attached to a printer, as it will be faxed. Section 1. Minnesota Birth Certificate Holder DetailsEnter the name of the birth certificate holder as it appears on the certificate...Birth Holder First* First name at birthMiddle* (or enter "None" or "Unknown")Birth Holder Last* Last name at birthSuffix*(none)Jr.Sr.IIIIIIIV(or "none") Birth City Birth County* HiddenState Minnesota (please check the box) Gender* Male Female Certificate Holder's Birth Date*MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Pick: Month / Day / YearBirth Hospital (if name is known) Adopted or Legal Name Change?*NoYesHas the name changed, (not counting a woman taking on a married last name)?Is Certificate Holder Alive?*YesNo Section 2. Parent InformationThe Mother's Maiden name and the Father (if known)IMPORTANT NOTE: To avoid delays, make sure the mother's maiden name is put below. Also, list the father's name if it is known and on the record of birth.Next, please enter the birth mother's maiden name...Mother's First* Mother's Middle* (or enter "None" or "Unknown")Mother Maiden Last Name* And, the Father of Record...Father's name is:* Known Not listed or Unknown Select oneFather's First Name* Middle* (or enter "None" or "Unknown")Father's Last* Suffix*(none)Jr.Sr.IIIIIIIV(or "none")Section 3. Contact InformationIMPORTANT NOTE: No PO Boxes. You must list a physical street address below (Also, no APO’s or FPO’s). It must be delivered to where someone can sign for the certificate..Ship to Full Name* The name that should appear on the envelope with the birth certificate in itShipping Address* Physical Address (no PO Boxes)City* State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZip* Best Phone No.* Best number for immediate contact!Second Phone The next best number to reach youEmail* Enter Email Confirm Email Section 4. Requester's VerificationThat's you, the person making request.IMPORTANT NOTE: The order can't be processed without your complete name here and may be delayed if left blank.Your First Name* Middle* (or "none")Your Last* Suffix*(none)Jr.Sr.IIIIIIIV(or "none")Your relationship to the birth certificate holder?*I am the birth certificate holderMotherFatherReason for request*Travel useEmergency travel/PassportPassportEntrance into armed forcesLegal reasonsSchool entranceEmploymentSocial SecurityRetirementDriver's licenseMarriage licenseWelfare assistanceVeteran's benefitCourt proceedingWorking papersIdentificationOtherYour Date of birth*MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Pick: Month/Day/YearYour Social Security Number* Section 5. Order OptionsAdditional Birth Certificates?Please enter a number from 0 to 5.The standard order includes one copy. Each additional copy adds $10.00.Additional Certificates CostTotal cost in dollars for the extra certificates ordered (this is not fillable).Add emergency speedier processing for $25?No thanksYes, I'll pay the additional $25This optional fee of $25.00 puts your job in front of regular jobs that came in before it, saving about 1 business day on average.)Section 6. Payment InfoCredit Card Type*Choose OneVisaVisa Debit CardMasterCardMasterCard Debit CardAmerican ExpressDiscoverCredit Card Number* Amex Card Number* Card Expiration* Format: mm-yyCVV Number* 3 digits on backAmex CVV Number* 4 digits on front rightName on Card* Exactly as it appearsCAUTION: The credit card address must match the credit card billing address if the certificate holder was born in CO, KS, LA, MD, MI, ME, MO, NH, NY, NC, PA, or VA.)Credit Card billing address is* Same as shipping address above Different address Credit Card Billing Address* City* State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZip* Section 7. Verification of info submittedTo help avoid unnecessary delays, please check each item after confirming it to be the case:Verification* The "ship to" name matches the requester's current name that is requesting the certificate. The mother's MAIDEN name was used in the last name of the "Mother's Name" field above. The father's name was filled out, if it is known. If a "success" page doesn't result after submitting, it means there are errors or information missing. These will be highlighted with red boxes. Once fixed, click "Submit" again. I understand I will need to print the fax forms I see after submission is successful I authorize USBirthcertificate.net to expedite my birth certificate for me. By pressing the submit button below I agree that I have read the order form completely and if the information that you have provided is incorrect, insufficient, or the government agency has no record of the birth that there are no refunds of USBirthcertificate.net's expedite services fee for any reason. I understand that USBirthcertificate.net is a private expediting service and I am hiring them to expedite my birth certificate order. (We don't create, change or amend birth records. We only help you retrieve existing records.) ALL SALES ARE FINAL. By clicking the submit button below you are sending your information electronically to our office to help speed the process your order. Once you click the button below you will be presented with form results which you'll need to print and fax to our office. Once it is signed and faxed your order cannot be cancelled. By clicking the button below you agree to these terms and the terms above. To continue the process and prepare a form to be printed, please hit the submit button below.Once the agreement is confirmed, click the submit button below. Be sure you get to the success page (otherwise check form for missing info.)* Yes, I agree to these terms. Go ahead and place my order. Once the agreement is confirmed, click the submit button below. Be sure you get to the success page (otherwise check form for missing info.) NameThis field is for validation purposes and should be left unchanged.