THE CEREMONY MUST BE PERFORMED WITHIN 90 DAYS FROM THE DATE…

           THE CEREMONY MUST BE PERFORMED WITHIN 90 DAYS FROM THE DATE LICENSE WAS ISSUED.
                            APPLICATION FOR PUBLIC MARRIAGE LICENSE
                                           NO REFUNDS

Groom's Personal Data
1A. NAME OF GROOM ­ FIRST (GIVEN)                         1B. MIDDLE                                1C. LAST (FAMILY)                                    2. DATE OF BIRTH ­ MONTH, DAY, YEAR


3A. RESIDENCE ­ Street Address                                              3B. CITY                                        3C. ZIP CODE               3D. COUNTY ­ IF NOT CAL.,              4.STATE (IF U.S.)
                                                                                                                                                       ENTER STATE (IF U.S.) OR               OR COUNTRY OF
                                                                                                                                                       COUNTRY                                BIRTH


5. MAILING ADDRESS ­ IF DIFFERENT                                           6. NUMBER. OF                    7A. LAST MARRIAGE ENDED BY:                                            7B. DATE ­ MM/DD/YYYY
                                                                            PREVIOUS MARRIAGES
                                                                                                               DEATH       DISSOLUTION         ANNULMENT

8A. USUAL OCCUPATION                                                        8B. USUAL KIND OF BUSINESS OR INDUSTRY                                                                  9. NUMBER OF HIGHEST
                                                                                                                                                                                    GRADE COMPLETED
                                                                                                                                                                                    (High School 1-12 or Univ. 13 ­ up)



10A. FULL NAME OF FATHER                                                    10B. STATE (IF U.S.) OR          11A. FULL MAIDEN NAME OF MOTHER                                        11B. STATE (IF U.S.) OR
                                                                            COUNTRY OF BIRTH                                                                                        COUNTRY OF BIRTH




Bride's Personal Data
12A. NAME OF BRIDE ­ FIRST (GIVEN)                    12B. MIDDLE                            12C. CURRENT LAST (FAMILY)                      12D. MAIDEN LAST (FAMILY) ­ IF               13. DATE OF BIRTH ­
                                                                                                                                             DIFFERENT THAN 12C                           MONTH, DAY, YEAR


14A. RESIDENCE ­ Street Address                                             14B. CITY                                       14C. ZIP CODE            14D. COUNTY ­ IF NOT CAL.,               15. STATE (IF U.S.)
                                                                                                                                                     ENTER STATE (IF U.S.) OR                 OR COUNTRY OF
                                                                                                                                                     COUNTRY                                  BIRTH


16. MAILING ADDRESS ­ IF DIFFERENT                                          17. NUMBER. OF                   18A. LAST MARRIAGE ENDED BY:                               18B. DATE ­ MM/DD/YYYY
                                                                            PREVIOUS MARRIAGES
                                                                                                               DEATH       DISSOLUTION         ANNULMENT

19A. USUAL OCCUPATION                                                       19B. USUAL KIND OF BUSINESS OR INDUSTRY                                                     20. NUMBER OF HIGHEST GRADE
                                                                                                                                                                        COMPLETED
                                                                                                                                                                        (High School 1-12 or Univ. 13 ­ Up)

21A. FULL NAME OF FATHER                                                    21B. STATE (IF U.S.) OR          22A. FULL MAIDEN NAME OF MOTHER                            22B. STATE (IF U.S.) OR COUNTRY
                                                                            COUNTRY OF BIRTH                                                                            OF BIRTH




Affidavit
We, the undersigned, an unmarried man and unmarried woman, state that the foregoing information is correct and true to the best of our knowledge and
belief, that no legal objection to the marriage nor to the issuance of a license is known to us, and hereby apply for a license and certificate of marriage.
23. SIGNATURE OF GROOM                                                            24. SIGNATURE OF BRIDE
                                                                                                        
Note: Authorization and license is hereby given to any person duly authorized by the laws of the State of California to perform a marriage ceremony within the State of California to solemnize the
marriage of the above named persons. Required consent for the issuance of this license is on file.


FOR OFFICE USE ONLY
25A. ISSUE DATE ­MONTH,DAY,YEAR                     25B. LICENSE EXPIRES AFTER                          25C. LICENSE NUMBER
                                                         MONTH, DAY, YEAR

                                                                                                                                                         BY:                                                  DEPUTY


                                                                   CITY HALL CEREMONY DATE: ____________________________________
                                                                                              AFFIDAVIT
I acknowledge that I have received the brochure entitled "Your Future Together..."


___________________________________________________________________                                        ______________________________________________________________________
Signature of Groom                                    Date                                                  Signature of Bride                                      Date


                                                                                     PRIVACY NOTIFICATION

The information requested for the marriage certificate is authorized and required by Division 9 of the Health and Safety Code, and related provisions within the Civil Code, Code of Civil
Procedures, and Government Code. Civil Code Section 1798.9 et seq. requires each state agency to provide this notice to individuals completing this form.

The principal purpose for this record is:
1.    To establish a permanent record that is legally recognized as prima facie evidence of the facts stated therein for each marriage occurring in the State of California.
2.    To provide individuals with certified copies from the records to serve their personal needs, such as securing passports and applying for social security or death benefits.
3.    To provide information to health authorities and other qualified persons with a valid education or scientific interest in demographic and epidemiological studies for health and social
      purposes.
4.    This information is also provided to the National Center for Health Statistics for compiling national reports.

The record shall be open for examination during regularly scheduled office hours, except when access is specifically prohibited by statute or regulations.