INFORMATION SHEET (please print clearly in black ink)

Date of Application:____________________

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

Groom's Age: __________________________________________________________________

Groom's Current Street Address:___________________________________________________

Groom's Current City:_____________________________ State:______ Zip Code: __________

Groom's Current Country: __________________________

Groom's Phone Number:__________________________________________________________
(Please include area code, and country code if outside of the USA)

Groom's E-mail address:__________________________________________________________

Groom's Father's First, Middle & Last Name: _________________________________________

Groom's Mother's First, Middle & Maiden Name: _______________________________________

Is this your first marriage?________________________________________________________

Full Name of Bride:_____________________________________________________________
(first, middle (no initials) and last name)

Bride's Age: __________________________________________________________________

Bride's Current Street Address:___________________________________________________

Bride's Current City:____________________________ State:_______ Zip Code: __________

Bride's Current Country: __________________________

Bride's Phone Number:___________________________________________________________
(Please include area code, and country code if outside of the USA)

Bride's E-mail address:_________________________________________________________

Bride's Father's First, Middle & Last Name: _________________________________________

Bride's Mother's First, Middle & Maiden Name: ________________________________________

Please type a brief statement as to why you want to get married by proxy instead of getting married in the traditional way.

 

 

 

Please type the complete address of where you want S&B Inc. to send the Marriage Certificate. We must have a street address.

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