ࡱ> 5@ bjbj22 XX<$4<<<h&==_?HGHGHGHGHGdHxIh9^;^;^;^;^;^;^$H`Rb_^5MHGHG5M5M_^HGHGL_QQQ5MHGHG9^Q5M9^QQQQHG? p[Q<QMdQQd b_0_Q~dMX~dQ$6~dQIJ|Q KdnKIII_^_^8< Q<New Jersey Department of Health and Senior Services APPLICATION FOR LICENSE FORMCHECKBOX MARRIAGE FORMCHECKBOX REMARRIAGE FORMCHECKBOX CIVIL UNION FORMCHECKBOX  REAFFIRMATION OF CIVIL UNION(PLEASE PRINT OR TYPE) DECLARATION OF APPLICANT A (Giving false information constitutes perjury.)DECLARATION OF APPLICANT B (Giving false information constitutes perjury.)1. Name (First, Middle, Last) (List name given at birth or on birth certificate)  FORMTEXT      1. Name (First, Middle, Last) (List name given at birth or on birth certificate)  FORMTEXT      Street Address (Current Legal Residence) (City, Borough, Twp.) (See Note 1)  FORMTEXT      Street Address (Current Legal Residence) (City, Borough, Twp.) (See Note 1)  FORMTEXT      County (See Note 4)  FORMTEXT      State  FORMTEXT      Zip Code  FORMTEXT      County (See Note 4)  FORMTEXT      State  FORMTEXT      Zip Code  FORMTEXT      1a. Current Name (if different)  FORMTEXT      2. Date of Birth  FORMTEXT      1a. Current Name (if different)  FORMTEXT      2. Date of Birth  FORMTEXT      3. Birthplace  FORMTEXT      4. Sex  FORMCHECKBOX M  FORMCHECKBOX F5. Age(See Note 2)  FORMTEXT      3. Birthplace  FORMTEXT      4. Sex  FORMCHECKBOX M  FORMCHECKBOX F5. Age(See Note 2)  FORMTEXT      6. Domestic Status (at this time) (See Notes 3 and 5)6. Domestic Status (at this time) (See Notes 3 and 5)DatePlaceDatePlace FORMCHECKBOX Single FORMCHECKBOX Single FORMCHECKBOX Widowed FORMTEXT       FORMTEXT       FORMCHECKBOX Widowed FORMTEXT       FORMTEXT       FORMCHECKBOX Divorced FORMTEXT       FORMTEXT       FORMCHECKBOX Divorced FORMTEXT       FORMTEXT       FORMCHECKBOX Annulled FORMTEXT       FORMTEXT       FORMCHECKBOX Annulled FORMTEXT       FORMTEXT       FORMCHECKBOX Current Domestic Partner FORMTEXT       FORMTEXT       FORMCHECKBOX Current Domestic Partner FORMTEXT       FORMTEXT       FORMCHECKBOX Former Domestic Partner FORMTEXT       FORMTEXT       FORMCHECKBOX Former Domestic Partner FORMTEXT       FORMTEXT       FORMCHECKBOX Former Civil Union Partner FORMTEXT       FORMTEXT       FORMCHECKBOX Former Civil Union Partner FORMTEXT       FORMTEXT      For Remarriage to the same spouse, or Reaffirmation of Civil Union to the same partner, enter date and place of original ceremony:For Remarriage to the same spouse, or Reaffirmation of Civil Union to the same partner, enter date and place of original ceremony:DatePlaceDatePlace FORMCHECKBOX Marriage  FORMCHECKBOX Civil Union FORMTEXT       FORMTEXT       FORMCHECKBOX Marriage  FORMCHECKBOX Civil Union FORMTEXT       FORMTEXT      7a. For Marriage License applicants, if applicable, enter number of times ever Married:  FORMTEXT      7b. For Civil Union applicants, if applicable, enter number of times ever in a Civil Union:  FORMTEXT      7a. For Marriage License applicants, if applicable, enter number of times ever Married:  FORMTEXT      7b. For Civil Union applicants, if applicable, enter number of times ever in a Civil Union:  FORMTEXT      8. Name of Most Recent Spouse/Partner (if any)  FORMTEXT      8. Name of Most Recent Spouse/Partner (if any)  FORMTEXT      9a. Father s Full Name  FORMTEXT      9b. Birthplace  FORMTEXT      9a. Father s Full Name  FORMTEXT      9b. Birthplace  FORMTEXT      10a. Mother s Full Maiden Name  FORMTEXT      10b. Birthplace  FORMTEXT      10a. Mother s Full Maiden Name  FORMTEXT      10b. Birthplace  FORMTEXT      11. Are you related to Applicant B?  FORMCHECKBOX Yes  FORMCHECKBOX No If  YES, how:  FORMTEXT      11. Are you related to Applicant A?  FORMCHECKBOX Yes  FORMCHECKBOX No If  YES, how:  FORMTEXT      INFORMATION TO BE COMPLETED BY EITHER APPLICANT12. In which Incorporated Municipality in New Jersey do you intend for the ceremony to be performed? (See Note 4)  FORMTEXT      13 Intended Date of Ceremony  FORMTEXT      14. Telephone Number where either applicant can now be reached.  FORMTEXT      15. Name and mailing address of person who is to perform the ceremony.  FORMTEXT      16. Mailing Address where you may be reached after the ceremony.  FORMTEXT      (See Notes on Page 2) Continue with Declaration of Identifying Witness and Oath. UPON COMPLETION, APPLICATION IS TO BE RETAINED AS A PERMANENT RECORD. DECLARATION OF IDENTIFYING WITNESS (Giving false information constitutes perjury) 1. Name (First, Middle, Last): Street Address: City, Borough, Township: County:State:Zip Code:2. Have the applicants correctly stated their ages and usual residences?  FORMCHECKBOX Yes  FORMCHECKBOX No3. 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In any case where application is made by only one applicant to begin the waiting period, the same identifying witness must return when the second applicant completes the application. In such a case the same witness must sign once again on the line below that on which he/she signed when appearing with the first applicant. We, who have hereunder signed our names, do solemnly swear (or affirm) that we are not currently ruled mentally incompetent, the answers given by us in this application for a marriage, remarriage, civil union, or reaffirmation of civil union license are true, full and perfect answers to each and all of said questions. Signature of Applicant A:Date: Signature of Applicant B:Date: Signature of Witness:Date: Second Signature of Witness (if necessary):Date:Sworn (or affirmed) and subscribed before me atthisday of, 20atAMPMSignature of Registrar:REGISTRAR - DO NOT insert place and date of ceremony or file the application until either the completed certificate or copy thereof is sent to you. Follow-up on all licenses for completion.License Number:Date of Issue:Ceremony Performed in (City, Borough, Twp.):Date of Ceremony: NOTE 1. This is the permanent home and principal establishment to which, when absent, the applicant intends to return. NOTE 2. Written consent of both parents is required for the marriage or civil union of any person under eighteen years of age. In addition, if any person is under sixteen, the consent of the parents must be approved in writing by a judge of the Superior Court, Chancery Division, Family Part. Consent of parents is required for the remarriage or reaffirmation of civil union of a minor previously married or joined in a civil union to the same partner in another state. NOTE 3. When a remarriage or reaffirmation of civil union license is requested, indicate in Question 6 that the parties are already married or joined in a civil union. It is required that proof of the previous marriage or civil union be submitted to you. Common law marriages, which were legal prior to December 1, 1939, must be established by affidavit showing the place and date of the common law marriage contract. The place and date of the previous marriage or civil union should be stated on both the application and the license. The seventy-two hour waiting period is waived. Consent of parents is required for the remarriage or reaffirmation of a civil union of a minor previously joined in a marriage or civil union to the same partner in another state. NOTE 4. If both applicants are nonresidents of New Jersey, the application must be made in the municipality where the ceremony will be performed. Registrar should mark the license accordingly. NOTE 5. The Registrar s review of a divorce decree, dissolution of Civil Union, or termination of Domestic Partnership, submitted with this application, in no way implies the validity of the submitted document. Such determination can only be made by a court of law. APPLICANTS MUST PROVIDE THEIR SOCIAL SECURITY NUMBERS (TITLE 37:1-17)Social Security Number of Applicant ASocial Security Number of Applicant B FORMTEXT   FORMTEXT   FORMTEXT  - FORMTEXT   FORMTEXT  - FORMTEXT   FORMTEXT   FORMTEXT   FORMTEXT   FORMTEXT   FORMTEXT   FORMTEXT  - FORMTEXT   FORMTEXT  - FORMTEXT   FORMTEXT   FORMTEXT   FORMTEXT  Social Security Numbers shall be kept confidential and may only be released for child support purposes and shall not be considered a public record pursuant to P. L. 1963, C.73 (C.47:1A-1 et seq.) 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