APPLICATION FOR A MARRIAGE CERTIFICATE PLEASE READ THESE NOTES before completing this form.

Marriage Certificate  Newcastle-Under-Lyme : C21/11/93

1 TO BE COMPLETED BY THE APPLICANT Name of applicant Mr Mrs Miss/Ms (STATE NAME IN FULL) Full postal address   Post Code: Telephone no: e-mail address:

2 Are you applying for your own marriage certificate? Yes/No If not please state your relationship to the person to whom the certificate relates:

3 DETAILS OF MARRIAGE CERTIFICATE REQUIRED
SPOUSE			PARTNER
SURNAME PEDLEY			SURNAME HAY	ANY OTHER SURNAME USED BEFORE THIS MARRIAGE
FORENAME(S) Harry C			FORENAME(S) Ann
DATE OF MARRIAGE			PLACE OF MARRIAGE
DAY	MONTH	YEAR 1921	NAME OF BUILDING, CHURCH OR REGISTER OFFICE AND LOCALITY Newcastle, St George

4 REQUIREMENTS	Send this Application to:
MARRIAGE CERTIFICATE £11.00	Superintendent Registrar, Register Office, Castle House, Barracks Road, Newcastle-Under-Lyme, Staffordshire, ST5 1BL, UK
I requireNUMBER marriage certificate(s)

5 REMITTANCE ENCLOSED  (POSTAL APPLICATIONS ONLY)
Payment by Credit Card only : Please add £2.00 for Post and Packaging, i.e. a total of £13.00 per certificate. A Priority Service is available for £35.00 + £2.00 for Post and Packaging.
If paying by Credit Card: Please debit my account by the amount: £		Type of card (e.g. Visa, Mastercard or Switch):
Name on Card:		Card Expiry Date (DD/MON/YYYY):
Enter both Card Number & Security Code. Card Number:                                       Security Code:
Signature:   Date:   Card Issue No. : (Switch only) Card Start Date (DD/MON/YYYY): (Switch only)
The Fee for a certificate issued against this form 'as printed' will not be refunded. You are strongly recommended to add any qualifying information you may have in order to help the registrar issue the correct certificate.