State of Connecticut
Department of Public Health
MARRIAGE LICENSE WORKSHEET
BRIDE / GROOM / SPOUSE BRIDE / GROOM / SPOUSE
NAME (First) (Middle) (Last)
NAME (First) (Middle) (Last)
SEX
DATE OF BIRTH (Mo., Day, Year)
AGE
SEX
DATE OF BIRTH (Mo., Day, Year)
AGE
BIRTHPLACE
EDUCATION (No. Yrs. Completed)
BIRTHPLACE
EDUCATION (No. Yrs. Completed)
GRADES
1-8
GRADES
9-12
COLLEGE
(1-5+)
GRADES
1-8
GRADES
9-12
COLLEGE
(1-5+)
RESIDENCE (No. and Street)
RESIDENCE (No. and Street)
CITY OR TOWN
COUNTY
STATE
CITY OR TOWN COUNTY
STATE
RACE
SUPERVISION OR CONTROL BY
GUARDIAN OR CONSERVATOR
YES NO
RACE
SUPERVISION OR CONTROL BY
GUARDIAN OR CONSERVATOR
YES NO
FATHER’S FULL NAME
FATHER’S FULL NAME
FATHER’S BIRTHPLACE
(State or Foreign Country)
MOTHER’S BIRTHPLACE
(State or Foreign Country)
FATHER’S BIRTHPLACE
(State or Foreign Country)
MOTHER’S BIRTHPLACE
(State or Foreign Country)
MOTHER’S FULL MAIDEN NAME MOTHER’S FULL MAIDEN NAME
NO. OF THIS
MARRIAGE
NO. OF
CIVIL UNIONS
IF PREVIOUSLY IN MARRIAGE OR
CIVIL UNION, LAST
RELATIONSHIP WAS
1. MARRIAGE 2. CIVIL UNION
NO. OF THIS
MARRIAGE
NO. OF
CIVIL UNIONS
IF PREVIOUSLY IN MARRIAGE
OR CIVIL UNION, LAST
RELATIONSHIP WAS
1. MARRIAGE 2. CIVIL UNION
LAST RELATIONSHIP ENDED BY:
1.
DEATH 2. DISSOLUTION 3. ANNULMENT
4.
PREVIOUS CIVIL UNION DID NOT END. MARRYING CIVIL UNION
PARTNER
LAST RELATIONSHIP ENDED BY:
1.
DEATH 2. DISSOLUTION 3. ANNULMENT
4.
PREVIOUS CIVIL UNION DID NOT END. MARRYING CIVIL UNION
PARTNER
SOCIAL SECURITY # OF BRIDE / GROOM / SPOUSE SOCIAL SECURITY # OF BRIDE / GROOM / SPOUSE
PHONE # OF BRIDE / GROOM / SPOUSE TOWN WHERE MARRIAGE CEREMONY WILL BE PERFORMED
OFFICIATOR’S NAME OFFICIATOR’S ADDRESS OFFICIATOR’S PHONE #
NOTICE: AS OF OCTOBER 1, 2009, YOU CAN ONLY APPLY IN THE TOWN WHERE THE CEREMONY IS TAKING PLACE.
THE LICENSE WILL ONLY BE VALID FOR 65 DAYS AFTER THE DATE OF APPLICATION.
For Office Use Only
Date Applied: Date Received for Record:
Date of Marriage:
Date License Issued: Amount Paid:
