NAME: DATE OF BIRTH / / PLACE OF BIRTH: PHONE NUMBER
APPLICANT ONE PLEASE COMPLETE ALL INFORMATION
NAME:__________________________________________DATE OF BIRTH____/___/____
FIRST
MIDDLE
LAST
MONTH/DAY/YEAR
PLACE OF BIRTH:________________________________PHONE NUMBER___________
CITY AND STATE/ FOREIGN COUNTRY
AGE:_________________SOCIAL SECURITY NUMBER:______________________________
CURRENT ADDRESS:____________________________________________________________
STREET
CITY
COUNTY
STATE
ZIP
MALE OR FEMALE____________NUMBER OF PREVIOUS MARRIAGES:_____________
MARITAL STATUS: NEVER MARRIED DIVORCED
WIDOW/WIDOWER
LAST MARRIAGE ENDED BY: DEATH
DIVORCE
ANNULMENT
DATE LAST MARRIAGE ENDED: MONTH____________DAY__________YEAR______
DATE OF BIRTH VERIFIED BY: DRIVER'S LICENSE STATE IDENTIFICATION
OTHER__________________________________________
EDUCATION:____________________________________________________________________
SPECIFY HIGHEST GRADE COMPLETED OR DEGREE
OCCUPATION:__________________________________________________________________
IS RESIDENCE INSIDE CITY LIMITS?
NO
YES
COLOR OR RACE_______________________ETHNICITY_____________________________
1. Are you now or have you ever been adjudged to be mentally incompetent?
NO
If answer is "yes" has the adjudication been removed?
NO
YES YES
2. Are you related to the applicant closer than second cousin?
NO
YES
3. Are you now under the influence of an alcoholic beverage?
NO
YES
4. Are you now under the influence of a narcotic drug?
NO
YES
5. List the full names and date of birth of any dependent children (custodial or non-custodial).
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
PARENTS:
FULL NAME OF FATHER:________________________________________________________
FIRST
MIDDLE
LAST
ADDRESS, CITY, STATE, ZIPCODE (if deceased, so state):_____________________________
BIRTHPLACE OF FATHER:_______________________________________________________
CITY & STATE / FOREIGN COUNTRY
FULL NAME OF MOTHER:_______________________________________________________
FIRST
MIDDLE
LAST
MAIDEN
ADDRESS, CITY, STATE, ZIPCODE (if deceased, so state):____________________________
BIRTHPLACE OF MOTHER:______________________________________________________
CITY & STATE / FOREIGN COUNTRY
SIGNATURE:________________________________________________________ NEW ADDRESS:_________________________________________________________________
Clerk Online Application forms 2009, revised July 2011, revised October 2014
APPLICANT TWO PLEASE COMPLETE ALL INFORMATION
NAME:______________________________________________DATE OF BIRTH____/___/____
FIRST
MIDDLE
LAST
MONTH/DAY/YEAR
PLACE OF BIRTH:________________________________PHONE NUMBER_______________
CITY AND STATE/ FOREIGN COUNTRY
AGE:_______________SOCIAL SECURITY NUMBER:________________________________
CURRENT ADDRESS:____________________________________________________________
STREET
CITY
COUNTY
STATE
ZIP
MALE OR FEMALE____________NUMBER OF PREVIOUS MARRIAGES:_____________
MARITAL STATUS: NEVER MARRIED DIVORCED
WIDOW/WIDOWER
LAST MARRIAGE ENDED BY: DEATH
DIVORCE
ANNULMENT
DATE LAST MARRIAGE ENDED: MONTH____________DAY__________YEAR_______
DATE OF BIRTH VERIFIED BY: DRIVER'S LICENSE STATE IDENTIFICATION
OTHER__________________________________________
EDUCATION:____________________________________________________________________
SPECIFY HIGHEST GRADE COMPLETED OR DEGREE
OCCUPATION:__________________________________________________________________
IS RESIDENCE INSIDE CITY LIMITS?
NO
YES
COLOR OR RACE_____________________________ETHNICITY_______________________
1. Are you now or have you ever been adjudged to be mentally incompetent?
NO
If answer is "yes" has the adjudication been removed?
NO
YES YES
2. Are you related to the applicant closer than second cousin?
NO
YES
3. Are you now under the influence of an alcoholic beverage?
NO
YES
4. Are you now under the influence of a narcotic drug?
NO
YES
5. List the full names and date of birth of any dependent children (custodial or non-custodial).
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
PARENTS:
FULL NAME OF FATHER:________________________________________________________
FIRST
MIDDLE
LAST
ADDRESS, CITY, STATE, ZIPCODE (if deceased, so state):_____________________________
BIRTHPLACE OF FATHER:_______________________________________________________
CITY & STATE / FOREIGN COUNTRY
FULL NAME OF MOTHER:_______________________________________________________
FIRST
MIDDLE
LAST
MAIDEN
ADDRESS, CITY, STATE, ZIPCODE (if deceased, so state):_____________________________
BIRTHPLACE OF MOTHER:______________________________________________________
CITY & STATE / FOREIGN COUNTRY
SIGNATURE:__________________________________________________________
NEW ADDRESS:_________________________________________________________________
Clerk Online Application forms 2009, revised July 2011, revised Oct. 2014
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