To save time, order your own birth certificate or the birth certificate of your child securely online and

pay with credit card.

Go to: http://vitalstats.gov.mb.ca/online_certificate_application.html

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Application for a Manitoba Birth Document

Please PRINT clearly to complete the front and back of this application.
Vital StaƟsƟcs Agency Incomplete applications or those with insufficient payment will be returned.

CONFIDENTIAL & RESTRICTED

PROTECTED B
When
completed DISPONIBLE EN FRANÇAIS
Section 1 - Applicant’s Mailing address
Name Daytime phone number(s)

Address
( ) -
( ) -
City Province Postal Code Email address

Section 2 - Type of document requested

Quantity
Birth Certificate with parents’ names ______
Birth Certificate without parents’ names ______
Copy of registration (this is not a birth certificate) ______

Reason for application : ______________________________________________________________________________________________________________________

DOCUMENT ISSUED IN: English OR French

Section 3 - Manitoba birth information

Last name on birth record First name Middle name(s)

Date of birth Sex

Male (M) Female (F) X

Month Day Year

Place of birth (town/city)

M A N I T O B A
Father or other parent
Last name First name Middle name(s)

Place of birth (province if born in Canada—country if born outside of Canada)

Mother or other parent

Maiden name First name Middle name(s)

Place of birth (province if born in Canada—country if born outside of Canada)

OFFICE USE ONLY

Checked: _____________

Entered: _____________
Reg. # _____________
_____________
Edited: _____________

Issued: _____________

Revised 04/20
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Section 4 - Applicant’s relationship to person named on certificate:
Check one box that applies to you and sign below:
Self, if the application is for your own certificate

Parent, either parent named on the record of the child

Legal guardian (submit a complete copy of guardianship papers)

Representative with written authorization from person entitled, parent, or guardian

Next-of-kin, if application is for a birth certificate for a deceased person
Familial relationship to deceased :_________________________________________________________________________________________
Date & place of death :__________________________________________________________________________________________________
Signature of eligible person : ___________________________________________________________________________________________________

Print name of eligible person: ___________________________________________________________________________________________________

Section 5 - Type of issuance service

REGULAR ISSUANCE SERVICE
Processing time is 6 to 8 weeks (shipping time is not included). Processing time may vary. Service is not available until documents for a vital event have
been filed in full, and registration has been completed without errors. Although a payment may be processed immediately, regular issuance service will
proceed after a vital event is registered correctly and in full.
- Delivered by Canada Post
- Fee: $30 per document
RUSH ISSUANCE SERVICE (! Signature required upon delivery! )
Processed within 3 business days (shipping time is not included). Selecting rush issuance service expedites processing of an application for a document.
It does not expedite registration of a vital event. Rush issuance service is not available until documents for a vital event have been filed in full, and
registration has been completed without errors. Although a payment may be processed immediately, rush issuance service will proceed after a vital event
is registered correctly and in full.
- Delivered by courier
- Fee: Canadian destination $65
US destination $75
International destination $105 Includes one document. Cheques for rush service must be certified.

Delivery address (if different than mailing address)

Name Company name (if applicable)

Street No. Street Name Apt. no. Buzzer No. PO Box

Postal Code City Province Country

Fees and service levels subject to change without notice, please check our website for current information. Phone number

Section 6 - Method of payment

Cash I authorize the Vital Statistics Agency to charge to my card: $________________
In person only
Debit card

MasterCard / Visa ! Fax only no email / Credit Card number Expiry date
! Fax seulement pas d'e-mail
204-948-3224
Money Order
Payable to the
Certified Cheque Minister of Finance Cardholder’s name Cardholder’s signature

- No post dated cheques will be accepted

- A $20 service fee will be charged on returned cheques
PROTECT YOUR CREDIT CARD INFORMATION—DO NOT SUBMIT BY EMAIL

Inquiries A $30 ADMINISTRATION FEE WILL BE RETAINED WHEN CUSTOMERS DO NOT

Telephone: 204-945-3701 RESPOND TO REQUESTS FOR ADDITIONAL INFORMATION REQUIRED TO
Toll-Free (within Canada) 1-866-949-9296 COMPLETE THE SERVICE.
Fax: 204-948-3128
E-Mail: [email protected] NOTICE UNDER THE FREEDOM OF INFORMATION AND
Web-Site: http://vitalstats.gov.mb.ca PROTECTION OF PRIVACY ACT
Address: Vital Statistics Agency The information requested on this form is collected pursuant to The Vital Statistics Act to
254 Portage Ave Wpg MB R3C 0B6 fulfill the requirements for the release of birth information. If you have any questions
regarding the collection or use of this information, please contact Vital Statistics Agency.

PROTECT YOUR PRIVATE AND CONFIDENTIAL INFORMATION – DO NOT SUBMIT BY EMAIL

Available in other formats upon request.