Application for Marriage License

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					                                                    TYPE / PRINT IN                                                                                                                       VIRGIN ISLANDS OF THE UNITED STATES
                                                     PERMANENT
                                                      BLACK INK.                                                                                                                LICENSE AND CERTIFICATE OF MARRIAGE
                                                         FOR
                                                    INSTRUCTIONS                                                                                          LICENSE NUMBER                                                                                                             STATE FILE NUMBER
                                                   SEE HANDBOOK.                                                                      1. GROOM'S NAME (First, Middle. Last)                                                                                                       2. AGE LAST BIRTHDAY




                                                                                                                                      3a. RESIDENCE – CITY, TOWN, OR LOCATION                                                           3b. COUNTY OR ISLAND



                                                                                                                             GROOM    3c. STATE                                             4a. BIRTHPLACE (State or Foreign Country) 4b. DATE OF BIRTH (Month, Day, Year) 5. SOCIAL SECURITY NO.




                                                                                                                                      6a. FATHER'S NAME (First, Middle. Last)                 6b. BIRTHPLACE (State         7a. MOTHER'S NAME (First, Middle. Maiden)             7b. BIRTHPLACE (State or
                                                                                                                                                                                                 or Foreign Country)                                                                  Foreign Country)




                                                                                                                                      8a. BRIDE'S NAME (First, Middle. Last)                                          8b. MAIDEN SURNAME (If different)                           9. AGE LAST BIRTHDAY
DEPARTMENT OF HEALTH AND HUMAN SERVICES — PUBLIC HEALTH SERVICE — NATIONAL CENTER FOR HEALTH STATISTICS — 1989 REVISION




                                                                                                                                      10a. RESIDENCE – CITY, TOWN, OR LOCATION                                                          10b. COUNTY OR ISLAND



                                                                                                                             BRIDE    10c. STATE                                                                                     11b. DATE OF BIRTH (Month, Day,
                                                                                                                                                                                            11a. BIRTHPLACE (State or Foreign Country)                                            12. SOCIAL SECURITY NO.




                                                                                                                                      13a. FATHER'S NAME (First, Middle. Last)                13b. BIRTHPLACE (State 14a. MOTHER'S NAME (First, Middle. Maiden)                   14b. BIRTHPLACE (State or
                                                                                                                                                                                                     or Foreign Country)                                                               Foreign Country)




                                                                                                                                             WE HERBY CERTIFY THAT THE INFORMATION PROVIDED IS CORRECT TO THE BEST OF OUR KNOWLEDGE AND BELIEF
                                                                                                                                                                AND THAT WE ARE FREE TO MARRY UNDER THE LAWS OF THIS STATE.
                                                                                                                          SIGNATURE   15. GROOM'S SIGNATURE                                                                 16. BRIDE'S SIGNATURE




                                                                                                                                      This License Authorizes the Marriage in This State of the Parties Named Above By Any                   17. EXPIRATION DATE (Month, Day, Year)
                                                                                                                                      Person Duly Authorized to Perform a Marriage Ceremony Under the Laws of the
                                                                                                                                      State of
                                                                                                                            LICENSE
                                                                                                                           TO MARRY   18. SUBSCRIBED TO AND SWORN TO BEFORE 19. SIGNATURE OF ISSUING OFFICIAL                                          20. TITLE OF ISSUING OFFICIAL
                                                                                                                                          ME ON: (Month, Day, Year)




                                                                                                                                      21. I CERTIFY THAT THE ABOVE NAMED                    22a. WHERE MARRIED – CITY, TOWN, OR LOCATION
                                                                                                                                                                                                                                       22b. ISLAND
                                                                                                                                      PERSONS
                                                                                                                                          WERE MARRIED ON: (Month, Day, Year)



                                                                                                                                      23a. SIGNATURE OF PERSON PERFORMING CEREMONY                                    23b. NAME (Type/Print)                                23c. TITLE


                                                                                                                           CEREMONY
                                                                                                                                      23d. ADDRESS OF PERSON PERFORMING CEREMONY (Street and Number or Rural Route Number, City or Town, State, Zip Code)




                                                                                                                                      24a. SIGNATURE OF WITNESS TO CEREMONY                                                 24b. SIGNATURE OF WITNESS TO CEREMONY




                                                                                                                                      25. SIGNATURE OF COURT REGISTRATION OFFICIAL                                                           26. DATE FILED BY COURT (Month, Day, Year)

                                                                                                                             LOCAL


                                                                                                                                             CONFIDENTIAL INFORMATION. THE INFORMATION BELOW WILL NOT APPEAR ON CERTIFIED COPIES OF THE RECORD.
                                                                                                                                                                   28. IF PREVIOUSLY MARRIED, LAST MARRIAGE                                                                 30. EDUCATION
                                                                                                                                       27. NUMBER OF THIS
                                                                                                                                                                                        ENDED                                  29. RACE – American                 (Specify only highest grade completed)
                                                                                                                                           MARRIAGE –
                                                                                                                                                                     By Death, Divorce,                                       Indian, Black, White, etc.
                                                                                                                                           First, Second, etc.                                                                                               Elementary/Secondary                 College
                                                                                                                                                                  Dissolution, or Annulment Date (Month, Day, Year)                (Specify below)
                                                                                                                                             (Specify below)                                                                                                        (0-12)                      (1-4 or 5+)
                                                                                                                                                                        (Specify below)
                                                                                                                                      27a.                       28a.                         28b.                          29a.                           30a.

                                                                                                                             GROOM

                                                                                                                                      27b.                       28c.                         28d.                          29b.                           30b.

                                                                                                                             BRIDE


                                                                                                                          PHS-T-004
                                                                                                                          REV. 1/89
(Please Type)                                                                                               No.
                                 APPLICATION FOR MARRIAGE LICENSE

We                                                           of
                                                                                      (Permanent Residence)

and                                                          of
                                                                                      (Permanent Residence)

      do hereby apply for and request that a marriage licence be granted us to enter into marriage in
                  ST. THOMAS                    ,Virgin Islands, and we do further respectfully represent that
      the following statements are true and correct:


                          MALE                                                           FEMALE
Full Name

SS No.

Date of Birth

Place of Birth

Nationality

Usual Residence

Previous Marital Status

Related to other Applicant?              NO                                                   NO
In what degree?                     N/A                                                      N/A

Parents:

      Present Name

      Maiden Name

      Place of Birth                     /                                                         /
Signature

      PLEASE CHECK THIS BOX IF YOU ARE                            THE COURT, HAVING REVIEWED THIS APPLICATION
      REQUESTING EXEMPTION TO THE EIGHT-DAY                       FOR MARRIAGE LICENSE, DETERMINING THAT
      POSTING REQUIREMENT EXPLAINED IN THE                        SPECIAL CIRCUMSTANCES EXIST TO ISSUE A
      ATTACHED MARRIAGE INFORMATION FACT                          LICENSE WITHOUT THE POSTING REQUIRED BY
      SHEET.                                                      TITLE 16 SECTION 38 OF THE VIRGIN ISLANDS
      WE ARE REQUESTING EXEMPTION BECAUSE
      OF THE FOLLOWING SPECIAL

                                                                                             JUDGE




Subscribed and sworn to by each of the parties this      day of                                               ,
License issued this             day of                                     ,
Filed this             day of                                     ,


                                                                  Clerk of the Territorial Court
                                                                  By:
                                                                                             Deputy Clerk

				
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