Application For License
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1
2New Jersey Department of Health
APPLICATION FOR LICENSE
MARRIAGE
REMARRIAGE
CIVIL UNION
REAFFIRMATION OF CIVIL UNION
(PLEASE PRINT OR TYPE)
DECLARATION OF APPLICANT A
DECLARATION OF APPLICANT B
(Giving false information constitutes perjury.)
(Giving false information constitutes perjury.)
1. Name (First, Middle, Last)
1. Name (First, Middle, Last)
(List name given at birth or on birth certificate/Maiden name)
(List name given at birth or on birth certificate/Maiden name)
Street Address (Current Legal Residence) (See Note 1)
County
Street Address (Current Legal Residence) (See Note 1)
County
Municipality of Residence (See Note 4)
State
Zip Code
Municipality of Residence (See Note 4)
State
Zip Code
1a. Current Name (if different)
2. Date of Birth
1a. Current Name (if different)
2. Date of Birth
3. Birthplace
4. Sex
)
3. Birthplace
4. Sex
)
5. Age(See Note 2
5. Age(See Note 2
M
M
F
F
6. Domestic Status (at this time) (See Notes 3 and 5)
6. Domestic Status (at this time) (See Notes 3 and 5)
Date
Place
Date
Place
Single
Single
Widowed
Widowed
Divorced
Divorced
Annulled
Annulled
Current Domestic
Current Domestic
Partner
Partner
Former Domestic
Former Domestic
Partner
Partner
Current Civil
Current Civil
Union Partner
Union Partner
Former Civil
Former Civil
Union Partner
Union Partner
For Remarriage to the same spouse, or Reaffirmation of Civil Union to the
For Remarriage to the same spouse, or Reaffirmation of Civil Union to the
same partner, enter date and place of original ceremony:
same partner, enter date and place of original ceremony:
Date
Place
Date
Place
Marriage
Marriage
Civil Union
Civil Union
7a. Enter number of times ever
7b. Name of Most Recent Spouse (if any) (List name
7a. Enter number of times ever
7b. Name of Most Recent Spouse (if any) (List name
Married (if applicable):
given at birth or on birth certificate/Maiden name):
Married (if applicable):
given at birth or on birth certificate/Maiden name):
8a. Enter number of times ever
8b. Name of Most Recent Civil Union Partner (if any)
8a. Enter number of times ever
8b. Name of Most Recent Civil Union Partner (if any)
in a Civil Union
(List name given at birth or on birth certificate/
in a Civil Union
(List name given at birth or on birth certificate/
(if applicable):
Maiden name):
(if applicable):
Maiden name):
9a. Parent’s Full Name at Birth
9b. Birthplace
9a. Parent’s Full Name at Birth
9b. Birthplace
10a. Parent’s Full Name at Birth
10b. Birthplace
10a. Parent’s Full Name at Birth
10b. Birthplace
Yes
No
Yes
No
11. Are you related to Applicant B?
11. Are you related to Applicant A?
If “YES,” how?
If “YES,” how?
INFORMATION TO BE COMPLETED BY
EITHER
APPLICANT
12. In which Incorporated Municipality in New Jersey do you intend for the ceremony
13 Intended Date of Ceremony
14. Telephone Number where either
to be performed? (See Note 4)
applicant can now be reached:
15. Name and mailing address of person who is to perform the ceremony:
16. Mailing Address where you may be reached after the ceremony:
(See Notes on Page 2)
Continue with Declaration of Identifying Witness and Oath.
REG-77
NOV 16
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