Marriage Certificate/extract Application Form - Queensland printable pdf download

Office use only

Court/QGAP:

Date:

(Version 7)

Court/QGAP Receipt No.:

Marriage certificate/extract application

Payment Amount:

BDM POS Receipt No.:

Effective as of 1 June 2010

BDM CORRES Receipt No.:

Births, Deaths and Marriages Registration Act 2003

Proof of identity is required with submission of this form. Please print clearly and do not use correction fluid.

1. Priority

(Only available if marriage is already registered)

Priority service

(attracts additional fee–visit to view fees)

2. Type of record

(

To view fees and commemorative designs visit )

Certified copy or

(indicate quantity) _______________

Short extract and/or

*Commemorative package

Specify design

____________________________

(indicate quantity) _______________

(additional fee) includes certified copy

3. Applicant’s details (*

To determine applicant eligibility visit for certificate access policy)

Your relationship to the person

Husband/Wife

named on the certificate

*Other

(please specify) _______________________________________________________________________

(tick option)

Reason certificate is required

First names

Signature of

applicant

Surname

Current residential address

(street, suburb, state and country)

Postcode

Telephone number

Mobile number

YYYY

Date of application

The personal information on this form is collected by the Registry of Births, Deaths and Marriages for the purpose of providing services and undertaking related activities.

Only authorised persons will have access to this information. Your details will not be disclosed to a third party without your consent unless the disclosure is authorised by law.

4. Postal details

(Non standard mail services will incur additional fees – visit to view fees)

First names Mr/Mrs/Dr/Ms/Miss

Surname

Postal address

(include country only if not Australia)

Postcode

5. Marriage details

Groom’s first names

Groom’s surname

Bride’s first names

Bride’s maiden name