Use a text only version of this form
Type of Request
*
:
--Click Here--
First time user
Update information
Unique Key reminder
If known, County X1 number or Unique Key:
(If requesting an ID change to a new X1 number, please include BOTH keys in this field.)
Last Name
*
:
First Name
*
:
Middle Initial
*
:
(enter NMI if no middle initial)
Maiden/Other Names:
Agency Name
*
:
Agency Street Address
*
:
City
*
:
State
*
:
(Example: MN)
Zip Code or Zip+4
*
:
(Example: 55378-1251)
Phone Number
*
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(10 digit example: 123-456-7890
)
Email Address
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