Application For License And Certificate Of Public Marriage - 2016 Page 2
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1
2MARK A. LUNN
Ventura County Clerk and Recorder
800 South Victoria Avenue Ventura, CA 93009-1260
(805) 654-2263
APPLICATION FOR LICENSE AND CERTIFICATE OF PUBLIC MARRIAGE
MUST BE LEGIBLE
1A. FIRST NAME
1B. MIDDLE
1C. CURRENT LAST
1D. LAST NAME AT BIRTH (IF DIFFERENT THAN 1C)
2. DATE OF BIRTH (MM/DD/CCYY)
3. STATE/COUNTRY OF BIRTH
4. # PREV. MARRIAGES / SRDP
5A. LAST MARRIAGE / SRDP ENDED BY:
5B. DATE ENDED (MM/DD/CCYY)
DEATH
DISSO
ANNULMENT
TERM SRDP
N/A
6. ADDRESS
7. CITY
8. STATE / COUNTRY
9. ZIP CODE
10A. FULL BIRTH NAME OF FATHER / PARENT
10B. STATE OF BIRTH (IF OUTSIDE U.S., ENTER COUNTRY)
11A. FULL BIRTH NAME OF MOTHER / PARENT
11B. STATE OF BIRTH (IF OUTSIDE U.S., ENTER COUNTRY)
12A.FIRST NAME
12B. MIDDLE
12C. CURRENT LAST
12D. LAST NAME AT BIRTH (IF DIFFERENT THAN 12C)
13. DATE OF BIRTH (MM/DD/CCYY)
14. STATE/COUNTRY OF BIRTH
15. # PREV. MARRIAGES / SRDP
16A. LAST MARRIAGE / SRDP ENDED BY:
16B. DATE ENDED (MM/DD/CCYY)
DEATH
DISSO
ANNULMENT
TERM SRDP
N/A
17. ADDRESS
18. CITY
19. STATE / COUNTRY
20. ZIP CODE
21A. FULL BIRTH NAME OF FATHER / PARENT
21B. STATE OF BIRTH (IF OUTSIDE U.S., ENTER COUNTRY)
22A. FULL BIRTH NAME OF MOTHER / PARENT
22B. STATE OF BIRTH (IF OUTSIDE U.S., ENTER COUNTRY)
WE, THE UNDERSIGNED DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF CALIFORNIA THAT WE ARE UNMARRIED AND THAT THE FOREGOING
INFORMATION IS TRUE AND CORRECT TO THE BEST OF OUR KNOWLEDGE AND BELIEF. WE FURTHER DECLARE THAT NO LEGAL OBJECTION TO THE MARRIAGE NOR TO THE
ISSUANCE OF A LICENSE IS KNOWN TO US. WE ACKNOWLEDGE RECEIPT OF THE INFORMATION REQUIRED BY FAMILY CODE SECTION 358 AND HEREBY APPLY FOR A LICENSE
AND CERTIFICATE OF MARRIAGE.
23. SIGNATURE OF PERSON LISTED IN FIELDS 1A-1D
24. SIGNATURE OF PERSON LISTED IN FIELDS 12A-12D
25. ISSUE DATE
26. EXPIRES AFTER (MM/DD/CCYY)
27. MARRIAGE LICENSE NUMBER
28. CLERK ISSUING LICENSE
NEW MIDDLE AND LAST NAME OF PERSON LISTED IN 1A-1D (IF ANY) FOR USE UPON SOLEMNIZATION OF THE MARRIAGE
30.A FIRST – MUST BE SAME AS 1A
30B. MIDDLE
30C. LAST
NEW MIDDLE AND LAST NAME OF PERSON LISTED IN 12A-12D (IF ANY) FOR USE UPON SOLEMNIZATION OF THE MARRIAGE
31A. FIRST – MUST BE SAME AS 12A
31B. MIDDLE
31C. LAST
NEW MIDDLE AND LAST NAME FIELDS
These fields may not be amended unless it is a clerical error and the amendment is signed by the county clerk or
his or her deputy and one of the parties to the marriage. If prior to marriage the couple wants to change or add the
new name(s) shown on the marriage license, the couple would then need to purchase a new marriage license. By
providing your initial below you are acknowledging you have read and understand this statement.
Initials: The couple understands the statement above:
_____________/_____________
Date of Marriage
Telephone Number
___________________________
______________________________________
Reset
CCR CLK 11 REV 06/01/2016
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