THIS FORM IS NOT FOR SALE REQUESTER’S DETAILS

Revised Form No. _______________

Your Name Last Name
Marriage Certificate
APPLICATION FORM
First Name (include JR., SR., II, III, IV, etc., if applicable)
Request for ☐ COPY ISSUANCE ☐ VIEWABLE ONLINE ☐ DOCPRINT Number
☐ AUTHENTICATION ☐ ENDORSEMENT ☐ PREMIUM ANNOTATION of Copies
Middle Initial
Requirements ☐ Your valid government-issued ID
☐ If Representative, valid government-issued ID of representative, signed authorization letter and valid
government-issued ID of the document owner Address House No., Street Name, Barangay

MReN, if known
_______________________________________________________________________
(Marriage Reference Number) 2 - -
City/Municipality, Province (Country if abroad)
The MReN can be found on the previously-issued PSA copy of the marriage certificate, if any.
_______________________________________________________________________
MARRIAGE CERTIFICATE DETAILS
Husband’s Mobile
Last Name
Number 0 9
Name

First Name (include JR., SR., II, III, IV, etc., if applicable)
PRIVACY NOTICE
Middle Name 1. I declare that I am the document owner/duly-authorized representative of the document
owner whose information appears in this application form. I further declare that I am fully
aware that the above data shall be used for application of copy issuance/authentication/
Wife’s certification of civil registry document.
Last Name (before marriage)
Maiden
Name 2. I give my consent to the processing of the above information subject to the exemptions
First Name provided by the Data Privacy Act and other applicable laws and regulations.

3. I trust that the above information shall remain confidential and shall only be retained for as
Middle Name (before marriage) long as necessary for the fulfillment of the declared, specified, and legitimate purpose, or
when the processing is relevant to such purpose, strictly in accordance with PSA’s records
retention policy.
Date of
Marriage 4. I further affirm that all the statements/information that appear in this application form are
Month Day Year true, correct, and complete to the best of my knowledge and belief.

Place of
Marriage ___________________________________________________________
PURPOSE OF YOUR REQUEST
☐ Claim Benefits/Loan
☐ Employment (Local)
☐ School Requirements
Conforme:
City/Municipality and Province (Country if married abroad)
___________________________________________________________ _____________________________________
Requester’s or Authorized Representative’s Signature over Printed Name Government-Issued ID No.
ACKNOWLEDGEMENT OF RECEIPT
☐ Passport/Travel: ______________________________ (Specify Country)
☐ Employment (Abroad): _________________________ (Specify Country)
Received by ____________________________________________ Date Received ______________________
☐ Others: _____________________________________ (Specify)
Signature over Printed Name

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