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2. 
5. One-Day Marriage Officiant License
9. Applicant Information
11. Applicant Name*

    First

12. Applicant Name*

    Last

14. Street Address*
16. City*

              

17. State*
18. Zip Code*
20. Telephone #*

              

22. Email *

              

24. Date of Birth*
    Date of Birth
28. Persons To Be Married

    (As appears on the marriage license)

30. Party #1*

    First

31. Party #1*

    Last

33. Street Address*
34. Date of Birth*
    Date of Birth
36. City*
37. State*
38. Zip Code*

40.                                 

42. Party #2*

    First

43. Party #2*

    Last

45. Street Address*
46. Date of Birth*
    Date of Birth
48. City*

              

49. State*
50. Zip Code*

54.   

      

        

      

58. 
    

    I duly swear/affirm under penalty of perjury that the information provided above is true and accurate.

60. Applicant Signature

    
    

    _________________________________________________________________

61. Date

          
         
    ______________________________

65. 
    

    Subscribed and sworn to (or affirmed) before me on this ________ day of ______________________, 20 ____, by _______________________________________________, proved to me on the basis of satisfactory evidence to be the person who appeared before me and signed.

67.      

         

    ______________________________________________________________
    Notary Signature

68.   

       

    _______________________________________
    Type of ID Provided

70.   

     (SEAL)

       

74. **For Office Use Only**

76. LICENSE:      APPROVED   /   DENIED

77. DATE:

79.      

         

    ____________________________________________________
    Town Clerk Signature

86. 
Leave This Blank:


87. Print Only

* indicates a required field