Application Entry - VLP.WebApp

* Denotes Required Fields

Officiant Name *

First Name(s):

Middle Name(s):

Last Name(s):

Suffix:

Officiant Address *

Line 1:

Line 2:

Line 3:

City:

State:

Zip:

Email Address: *

Phone Number: *

Are you 21 years of age or older?:

Yes No

Date of Birth: *

Are you registering as minister of a religious denomination?:

Yes No

If registering as a minister of any denomination, you must file a copy of your credentials at the time of application.

Are you filing a copy of credentials of license or ordination?:

Yes No

If credentials expire, when?: