Transcription of REG-77A, Application for Marriage, Remarraige, Civil Union ...
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REG-77A, Application for Marriage, Remarraige, Civil Union ...
REG-77A APR 19 Page 1 of 4 Pages. New Jersey Department of Health El Departamento de Salud de New Jersey Application FOR LICENSE SOLICITUD PARA LICENCIA MARRIAGE REMARRIAGE Civil Union REAFFIRMATION OF Civil Union MATRIMONIO REMATRIMONIO UNI N Civil REAFIRMACI N DE UNI N Civil (PLEASE PRINT OR TYPE) / (INMPRIMA O USE LETRA DE MOLDE) DECLARATION OF APPLICANT A DECLARACI N SOLICITANTE A (Giving false information constitutes perjury.) (Proveer informaci n falsa constituye perjurio) DECLARATION OF APPLICANT B DECLARACI N SOLICITANTE B (Giving false information constitutes perjury.)
Nombre (Primer, Segundo, Apellido) (Inscrito en el acta de nacimiento o de soltera) 1. Name (First, Middle, Last) (List name given at birth or on birth certificate/Maiden name) Nombre (Primer, Segundo, Apellido) (Inscrito en el acta de nacimiento o de soltera) Street Address
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