INFORMATION SHEET (please print clearly in black ink)

Date of Application:____________________

Name of Groom:___________________________________________________________
(first, middle (no initials) and last name)

Groom's date of birth: __________________________________________________________________
(day, month and year)

Groom's age __________

Groom's mother's name: ______________________________________________
(first, middle (no initials) and maiden name)

Groom's father's name: ______________________________________________
(first, middle (no initials) and last name)

Groom's present address:________________________________________________

Groom's city:_____________________________

Groom's state:______

Groom's Zip Code: __________

Groom's country: __________________________

Groom's home phone number:_____________________________________
(Please include area code, and country code if outside of the USA)

Groom's cell phone number:_____________________________________
(Please include area code, and country code if outside of the USA)

Groom's E-mail address:__________________________________________________________

Bride's Name:___________________________________________________________
(first, middle (no initials) and last name)

Bride's date of birth: __________________________________________________________________
(day, month and year)

Bride's age __________

Bride's mother's name: ______________________________________________
(first, middle (no initials) and maiden name)

Bride's father's name: ______________________________________________
(first, middle (no initials) and last name)

Bride's present address:________________________________________________

Bride's city:_____________________________

Bride's state:______

Bride's Zip Code: __________

Bride's country: __________________________

Bride's home phone number:_____________________________________
(Please include area code, and country code if outside of the USA)

Bride's cell phone number:_____________________________________
(Please include area code, and country code if outside of the USA)

Bride's E-mail address:__________________________________________________________

Please answer the following questions:

1.Who will be traveling to Denver Colorado?

 

2.What is the approximate date of travel?

 

3.Please state briefly the reason you are getting married by proxy.

 

4. In order to qualify for a Colorado Single Poxy Marriage, it is necessary for the parties to have met in person.

Name of the place you met: ____________________________________

Month and year you met: ______________________________________

5.How did you find out about our company?

 

Please print the complete address of where you want S&B Inc. to send the Marriage Certificate.

Name: _________________________________________________________________

Street Address: _____________________________________________

City: ____________________________________ State: ________ Zip Code: __________

Country: ____________________________________

PLEASE FAX THIS FORM AND THE CREDIT CARD AUTHORIZATION FORM TO: 610-644-2860
OR E-MAIL BOTH FORMS TO shmulick@yahoo.com

OUR TOLL FREE NUMBER IS: 1-877-482-2406