State Of Maine Temporary Officiate Application Form - Maine Department Of Health And Human Services
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Maine Center for Disease Control and Prevention (Maine CDC)
220 Capitol Street
11 State House Station
Augusta, Maine 04333-0011
(207) 287-3771
Fax : (207) 287-1093
TTY Users: Dial 711 (Maine Relay)
Reset Form
State of Maine Temporary Officiate Application
Note: This application is valid only for the marriage solemnization for the individuals specified on the
application within the State of Maine by the individual who is not otherwise authorized to do so.
I hereby request the State Registrar to designate me to solemnize a particular marriage for the individuals listed
on this application.
Applicant Information
Full name:_______________________________________________________________________________
Street: ___________________________________________ Email: ________________________________
City/State/Zip: ___________________________________________________________________________
Officiates Title:_______________________________________ Phone: _____________________________
Authorization Date or Commission Expiration ________________________ Date of Birth:_____________
Party A Information
Name:____________________________________________________________________________________
(First)
(Middle)
(Last)
Street/P.O. Box: ____________________________________________________________________________
City:____________________________ State: __________________________ Zip:_____________________
Date of Birth: ______________________________________
Phone: __________________________
Party B Information
Name:____________________________________________________________________________________
(First)
(Middle)
(Last)
Street/P.O. Box: ____________________________________________________________________________
City:____________________________ State: __________________________ Zip:_____________________
Date of Birth: _
Phone: __________________________
_________
____________________________
City/Town of Wedding: _____________________________ Date of Proposed Marriage: ________________
I certify under penalty of perjury that all information on this form is accurate.
Applicant Signature: _____________________________________________ Date: ____________________
Return this application along with the $100 processing fee in the form of a check or money order made payable
to Treasurer State of Maine to the address listed above. Should you have any questions while completing this
form, please contact a member of the Maine CDC vital records office at (207) 287-6490.
DRVS Approval Number: ______________________ Temporary Officiate Expiration Date: _______________
State Registrar Signature: ________________________________________ Date Approved: _______________
S\vradminf\AMaster forms officiateapplic.pdf R 02/2014
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