KENT COUNTY CLERK
APPLICANT
____________________________________________________________________
FULL NAME (FIRST, MIDDLE, LAST)
____________________________________________________________________
SURNAME ON BIRTH CERTIFICATE (IF DIFFERENT)
____________________________________________________________________
STREET ADDRESS
____________________________________________________________________
CITY, STATE & ZIP CODE
__________________ _______________________________________________
RESIDENT COUNTY SOCIAL SECURITY NUMBER
___________________ _______________________________________________
PRESENT AGE DATE OF BIRTH - MONTH/DAY/YEAR
___________________________ ______________________________________
TIMES PREVIOUSLY MARRIED SEX
____________________________________________________________________
PHONE NUMBER
____________________________________________________________________
EMAIL
____________________________________________________________________
BIRTHPLACE - CITY & STATE
____________________________________________________________________
FATHER’S FULL NAME
______________________________________ _____________________________
FATHER’S STATE OF BIRTH OR COUNTRY SURNAME AT BIRTH
____________________________________________________________________
MOTHER’S FULL NAME
______________________________________ ____________________________
MOTHER’S STATE OF BIRTH OR COUNTRY SURNAME AT BIRTH
APPLICANT
____________________________________________________________________
FULL NAME (FIRST, MIDDLE, LAST)
____________________________________________________________________
SURNAME ON BIRTH CERTIFICATE (IF DIFFERENT)
____________________________________________________________________
STREET ADDRESS
____________________________________________________________________
CITY, STATE & ZIP CODE
__________________ _______________________________________________
RESIDENT COUNTY SOCIAL SECURITY NUMBER
___________________ _______________________________________________
PRESENT AGE DATE OF BIRTH - MONTH/DAY/YEAR
___________________________ ______________________________________
TIMES PREVIOUSLY MARRIED SEX
____________________________________________________________________
PHONE NUMBER
____________________________________________________________________
EMAIL
____________________________________________________________________
BIRTHPLACE - CITY & STATE
____________________________________________________________________
FATHER’S FULL NAME
______________________________________ _____________________________
FATHER’S STATE OF BIRTH OR COUNTRY SURNAME AT BIRTH
____________________________________________________________________
MOTHER’S FULL NAME
______________________________________ ____________________________
MOTHER’S STATE OF BIRTH OR COUNTRY SURNAME AT BIRTH
