MARRIAGE LICENSE APPLICATION
APPLICANT A INFORMATION:
_____Bride _____Groom _____Spouse _____MALE _____FEMALE
NAME:
Appearance Order on Marriage Certificate & License: Line 1____ / Line 2____
FIRST
______
____
_____________MIDDLE_________________LAST_______________________________
BIRTH NAME
(IF DIFFERENT THAN ABOVE) _____________________________________________________
MARITAL STATUS:
_____SINGLE _____ DIVORCED _____ WIDOWED _____ UNDER CONTROL OF GUARDIAN
CURRENT RESIDENCE:
STREET________________________________________________________________________________
CITY_____________________ STATE________________ ZIP ______________ COUNTY_____________
PRIOR ADDRESS WITHIN LAST 6 MONTHS:
(IF DIFFERENT THAN ABOVE)
STREET _______________________________________________________________________________
CITY_________________STATE______________ ZIP CODE_____________ COUNTRY_____________
BIRTH INFORMATION:
DATE OF BIRTH_____________________ AGE___________
BIRTH STATE
(PROVIDE COUNTRY IF OUTSIDE U.S.A.) __________________________________
PARENTS INFORMATION:
MOTHER/PARENT’S BIRTH NAME_______________________________________________________
FATHER/PARENT’S BIRTH NAME____________________________________________________
MOTHER/PARENT’S BIRTH STATE____________ FATHER/PARENT’S BIRTH STATE_______________
(PROVIDE COUNTRY IF OUTSIDE U.S.A.) (PROVIDE COUNTRY IF OUTSIDE U.S.A.)
SOCIAL SECURITY NUMBER: ___________________________________
CURRENT PHONE NUMBER: ____________________________________
FOR OFFICIAL USE ONLY:
DATE OF EXPIRATION: ____________________ LICENSE NUMBER: ___________________
FEE: $64.00
c
ash, credit card or cashier’s check
PLANNED DATE OF MARRIAGE
______________
