Full Name of
Groom and Bride:
First / Middle / Last |
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If name on driver's license differs from
Birth Certificate enter Birth Certificate name here.
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Social Security #
(if living in US) or Passport # and country of Passport if not a
US citizen: |
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| Date of Birth
(mm/dd/yyyy) |
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| Enter the State or Foreign
Counrty of Birth. |
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| Day Time Phone: |
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Race:
□White □
Black □ Hispanic □American Indian □ Asian
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Other |
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You presently reside in:
(City) (State )(County) |
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| Number of this Marriage: |
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Last marriage ended in:
□Divorce □Death □Annulment
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Last marriage ended on: (Month)(Day) (Year) |
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