* SPECIFY ADDRESS WHERE CERTIFICATE OF MARRIAGE SHOULD BE SENT
ADDRES
:
BGS PHONE NUMBE
:
BGS PHONE NUMBE
:
Name:
* THIS IS NOT A MARRIAGE LICENSE TNH TIC Icg tc by:jwb 2011
Bride/Groom/Spouse Bride/Groom/Spouse
1. A. FULL NAME:
11. A. FULL NAME:
FIRST MIDDLE CURRENT SURNAME
FIRST MIDDLE CURRENT SURNAME
B. BIRTH NAME (if different):
B. BIRTH NAME (if different):
C. SURNAME AFTER MARRIAGE:
(Optional – See Reverse)
C. SURNAME AFTER MARRIAGE:
(Optional – See Reverse)
D. SOCIAL SECURITY NUMBER:
D. SOCIAL SECURITY NUMBER:
2. RESIDENCE: A. B. 12. RESIDENCE: A.
B.
(STATE) (COUNTY)
(STATE)
(COUNTY)
C. CHECK ONE
AND
SPECIFY
CITY TOWN
VILLAGE
C. CHECK ONE
AND
SPEICFY
CITY
TOWN
VILLAGE
D. STREET ADDRESS:
ZIP:
D. STREET ADDRESS:
ZIP:
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORTATED VILLAGE?
YES
NO
E. IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORTATED VILLAGE?
YES
NO
3. A. AGE: B. DATE OF BIRTH: C. SEX (optional): 13. A. AGE: B. DATE OF BIRTH: C. SEX (optional):
4. EMPLOYMENT
A. USUAL OCCUPATION:
14. EMPLOYMENT
A. USUAL OCCUPATION:
B. TYPE OF INDUSTRY OR BUSINESS:
B. TYPE OF INDUSTRY OR BUSINESS:
5. PLACE OF BIRTH:
15. PLACE OF BIRTH:
6. FATHER OR PARENT
A. NAME (or maiden name, if applicable):
16. FATHER OR PARENT
A. NAME (or maiden name, if applicable):
B. COUNTRY OF BIRTH:
B. COUNTRY OF BIRTH:
7. MOTHER OR PARENT
A. NAME (or maiden name, if applicable):
17. MOTHER OR PARENT
A. NAME (or maiden name, if applicable):
B. COUNTRY OF BIRTH:
B. COUNTRY OF BIRTH:
8. NUMBER OF THIS MARRIAGE:
18. NUMBER THIS MARRIAGE:
9. PREVIOUS MARRIAGES 19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE:
CIVIL ANNULMENT:
DEATH:
DIVORCE:
CIVIL ANNULMENT:
DEATH:
B. HOW DID LAST MARRIAGE END?
DIVORCE (3)
NNULMENT (3)
DEATH
(2)
B. HOW DID LAST MARRIAGE END?
DIVORCE (3)
NNULMENT (3)
DEATH (2)
C. DATE LAST MARRIAGE ENDED?
C. DATE LAST MARRIAGE ENDED?
D. ARE ANY FORMER SPOUSE(S) ALIVE?
YES
NO
D. ARE ANY FORMER SPOUSE(S) ALIVE?
YES
NO
10. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
20. IF PREVIOUSLY DIVORCED OR ANNULLED, PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM DATE OF DECREE PLACE ISSUED AGAINST WHOM
(Month/Day/Year) (City/County, State/Country, If not USA) SELF SPOUSE (Month/Day/Year) (City/County, State/Country, If not USA) SELF SPOUSE
1ST
1ST
2ND
2ND
3RD
3RD
4TH
4TH
TOWNOFNORTHHEMPSTEAD
MARRIAGELICENSEAPPLICATION WORKSHEET
DATE:
