1. that I am a Canadian Citizen

__ by birth OR

__ by naturalization

2.that I am the bearer of Canadian Passport number _____________ issued at _______________ on ___ / ___ / 20___, where my personal information appears as follows:

Last name(s): __________________________________

Given name(s): __________________________________

Date of birth: __________________________________

Place of birth (city and country): __________________________________

3. that my parents are/were:

Father’s last name(s): __________________________________

Father’s given name(s): __________________________________

__ living __ deceased

Mother’s last name(s) at birth (maiden): __________________________________

Mother’s given name(s): __________________________________

__ living __ deceased

4. that my current residential address is:

_____________________________________________________________________

_____________________________________________________________________

5. that, if different, my last address in Canada was

_____________________________________________________________________

_____________________________________________________________________

6. that I am the holder of the long-form Canadian birth certificate no. ________________ issued by the Province/Territory of ________________ on ___ / ___ / _____

OR

that I am the holder of the Certificate of Canadian Citizenship number __________________ issued on ___ / ___ / _____

7. that I am free to marry as I am

__ single and never previously married

__ widowed; indicate the full name of the spouse, as well as the date and place of death

____________________________________________________________

__ divorced; indicate the full name of the ex-spouse, as well as the details of the final divorce decree

____________________________________________________________

8. that I intend on marrying the following person:

Last name(s): __________________________________

Given name(s): __________________________________

Date of birth: __________________________________

Place of birth (city and country): __________________________________

Father’s last name(s): __________________________________

Father’s given name(s): __________________________________

__ living __ deceased

Mother’s last name(s) at birth (maiden): __________________________________

Mother’s given name(s): __________________________________

__ living __ deceased

9. that this person’s current residential address is:

_____________________________________________________________________

_____________________________________________________________________

10. that my telephone and/or cell phone number, as well as e-mail address, are:

Home: __________________________________

Cell phone: __________________________________

E-mail: _______________________@__________________________

11. that the person I intend on marrying (per item 8 above) and I are not related either by blood or marriage (article 87 Codice Civile)

12. that neither I nor the person I intend on marrying (per item 8 above) have ever been convicted for the attempted or successful murder of the other person’s former spouse(s) (article 88 Codice Civile)