STATE OF MINNESOTA

STATE OF MINNESOTA

VITAL RECORD ORDER FORM
When you are ready to place an order for Vital Records paper, please complete this order form in full and select the SUBMIT button at the bottom of the page. You will receive a confirmation by e-mail that your order was received.

Contact Northstar at 763.531.7375 if you have any questions.
Local Office (Full Name):
PO#
Purchasing Agent:
Date:
Phone Number:
Email:
Bill To Location:
Ship To Location:
Bill To Attn:
Ship To Attn:
Bill To Street Address
Ship To Street Address:
Bill To Suite:
Ship To Suite:
Bill To City, State, Zip:
Ship To City, State, Zip:
QUANTITY*
LOCATION PREFIX*
START NUMBER - PLEASE INCLUDE LEADING ZEROS*
ENDING NUMBER- PLEASE INCLUDE LEADING ZEROS
SPECIAL REQUEST, COMMENTS OR INSTRUCTIONS:
YOU WILL BE INVOICED

PLEASE SUBMIT PAYMENT BY CHECK
If you have questions about the security paper contract, policies or procedures related to issuing certificates, please contact the Minnesota Department of Health, Office of Vital Records by e-mail at health.issuance@state.mn.us or phone at 651-201-5980
Email
example@example.com
Revised July 2, 2018
Should be Empty: