License Application

Stacy M. Butterfield, CPA

Clerk of the Circuit Court & Comptroller

Polk County, Florida

Spouse 1

First Name

Middle Name

Last Name

Suffix

Proof of Identification

Address

City

County

State

Zip

Phone#

Resident Country

Birth State

Birth Country

DOB

Age

Social Security #

This Marriage #

Birth/Maiden Name

Last Marriage Ended In

Date Last Marriage Ended on

Spouse 2

First Name

Middle Name

Last Name

Suffix

Proof of Identification

Same Address

Address

City

County

State

Zip

Phone#

Resident Country

Birth State

Birth Country

DOB

Age

Social Security #

This Marriage #

Birth/Maiden Name

Last Marriage Ended In

Date Last Marriage Ended on

Please verify that you are not a robot