Senator Mike Bernskoetter

Resolution Fact Sheet - Birth


First, please give us your name, address, phone and email address.

Name:
Address:
City:
State:
Zip:
Phone:
Email address:

Now we need information regarding the resolution.

Date Resolution Needed: (mm/dd/yyyy)
Baby's full name:  
Names of parents:  
City of residence:  
Date of birth:
Time of birth:
Weight:
Length:
Medical facility where born:  
Siblings:
Grandparents:
Great-Grandparents:
Other close family members:
Occupation of parents:
Father:
Mother:
Other pertinent information:
Mailing instructions: