(a) The marriage license application shall be in the form prescribed and provided by the Department of Health and Social Services and shall be permanently preserved by the issuing officer in the manner as prescribed by the Department of Health and Social Services. The marriage license application shall include the following information and such other information as prescribed by the Department of Health and Social Services:
(b) The application shall contain a certification by each applicant that each applicant is not of a prohibited degree of relationship.
(c) The applicants and issuing officer shall sign the application and the issuing officer shall certify as follows:
“I believe neither party is now under the influence of intoxicating liquor nor a narcotic drug. I have demanded and examined such papers as are required by law and I am satisfied that they are properly executed. I know of no legal impediment to the proposed marriage of the above applicants.”
The application shall also contain an appropriate affidavit form to be signed by persons certifying that an applicant is a resident of the State, if such certification is required.