Application for Marriage License or Certificate - Hawaii
Your marriage record is vital.
Be sure the information you give is complete and accurate.
PLEASE PRINT – USE BLACK INK
MARRIAGE LICENSE APPLICATION
TO BE FILLED OUT BY COUPLE MAKING APPLICATION
(Please read instructions on reverse side of this form)
STATE OF HAWAI’I DEPARTMENT OF HEALTH
OFFICE OF HEALTH STATUS MONITORING
LICENSE NO.
APPLICANT I
Zip Code
Groom
Bride
Spouse
1a. FIRST NAME OF APPLICANT I b. MIDDLE NAME c. LAST NAME
1d. SOCIAL SECURITY NO.
2. DATE OF BIRTH (Month, Day, Year)
3. USUAL RESIDENCE: a. STREET ADDRESS
CITY
b. COUNTY
c. STATE OR FOREIGN COUNTRY
4. PLACE OF BIRTH: *City & State/Country
5. FATHER: a. FULL NAME – FIRST, MIDDLE, LAST
b. STATE OR FOREIGN COUNTRY OF BIRTH*
c. Living?* Yes, No,
Refused, or Unknown
6. MOTHER: a. FULL NAME – FIRST, MIDDLE, MAIDEN NAME
b. STATE OR FOREIGN COUNTRY OF BIRTH*
c. Living?* Yes, No,
Refused, or Unknown
APPLICANT II
Zip Code
Groom
Bride
Spouse
7a. FIRST NAME OF APPLICANT II b. MIDDLE NAME c. LAST NAME
7d. SOCIAL SECURITY NO.
8. DATE OF BIRTH (Month, Day, Year)
9. USUAL RESIDENCE: a. STREET ADDRESS
CITY
b. COUNTY
c. STATE OR FOREIGN COUNTRY
10. PLACE OF BIRTH: *City & State/Country
11. FATHER: a. FULL NAME – FIRST, MIDDLE, LAST
b. STATE OR FOREIGN COUNTRY OF BIRTH*
c. Living?* Yes, No,
Refused, or Unknown
12. MOTHER: a. FULL NAME – FIRST, MIDDLE, MAIDEN NAME
b. STATE OR FOREIGN COUNTRY OF BIRTH*
c. Living?* Yes, No,
Refused, or Unknown
Blood relationship of Applicant I
to Applicant II:
In what county do you plan to be married?
(Honolulu, Hawai’i Maui,
or Kaua’i County)
When do you plan to be married?
Name of Marriage Performer (Commissioned by the State of Hawai’i)
FORWARDING ADDRESS:
(After Marriage)
DO YOU WANT YOUR NAMES YES NO
PRINTED OR POSTED ELECTRONICALLY IN THE NEWSPAPER?
E-MAIL ADDRESS:
HOME/CELL PHONE NUMBER:
WORK PHONE NUMBER:
CONFIDENTIAL INFORMATION – PLEASE COMPLETE
SUPPLEMENTARY
DATA
NO. OF THIS
MARRIAGE/OTHER
LEGAL UNION
CURRENTLY
IN CIVIL UNION OR
OTHER LEGALLY
RECOGNIZED
UNION WITH SAME
PARTNER?
IF PREVIOUSLY MARRIED OR IN OTHER LEGALLY RECOGNIZED
UNION, LAST MARRIAGE/OTHER LEGAL UNION ENDED.
RACE*
OCCUPATION*
EDUCATION* -
Specify Highest
Grade
Completed
SEX
FIRST, SECOND,
ETC. (SPECIFY)
BY DEATH, DIVORCE,
DISSOLUTION,
ANNULMENT OR
TERMINATION (specify)
DATE ENDED
PLACE ENDED
(COUNTY & STATE)
MONTH YEAR
APPLICANT I
21a.
21b.
22a.
22b.
22c.
23.
24.
25.
26.
APPLICANT II
27a.
27b.
28a.
28b.
28c.
29.
30.
31.
32.
FOR OFFICE USE ONLY
CERTIFICATION - SIGN BEFORE MARRIAGE AGENT
APPLICANT I:
SIGHTED:
#:
NAME ? Yes No
DOB ? Yes No
AGE: Sex: M F
Previous Marriage(s)/Legal
Union(s):
APPLICANT II:
SIGHTED:
#:
NAME ? Yes No
DOB ? Yes No
AGE: Sex: M F
Previous Marriage(s)/Legal
Union(s):
We, the undersigned, certify that the information given in this application is true and correct to be best of our knowledge and belief.
FULL SIGNATURE OF APPLICANT I
FULL SIGNATURE OF APPLICANT II
Sworn and subscribed to before me this day of , 20
MARRIAGE LICENSE AGENT JUDICIAL DISTRICT, STATE OF HAWAI’I
OHSM-1 ITEMS INDICATED WITH * ARE OPTIONAL, BUT DO NOT LEAVE THESE ITEMS BLANK; ENTER REFUSED INTENTIONAL FALSIFICATION IS A CRIME
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