Our Lady of Pompeii Church

Today’s Date: ______Mem. I.D. # Our Lady of Pompeii Church 355 Foxon Rd., East Haven, CT 06513 Phone: (203) 469-0764 Fax: (203) 469-3645

FAMILY NAME: ______

ADDRESS: ______

______

MARITAL STATUS: ___Single ___Married ___Divorced ___Widowed

CHURCH/PLACE WHERE MARRIED ______TOWN______STATE ____ DATE MARRIED ______PHONE NUMBERS:

HOME: ______

WORK #(s): 1. ______Mr./Mrs./Ms. 2. ______Mr./Mrs./Ms.

CELLULAR #(s): 1.______Mr./Mrs./Ms. 2. ______Mr./Mrs./Ms.

EMAIL ADDRESS: ______

HEAD OF HOUSEHOLD INFORMATION:

1. NAME: ______Maiden Name (If Applicable) ______Gender: ____ Male ____Female Date of Birth: ______Place/Town/State of Birth: ______Relationship: ____Head ___ Spouse/Sig.Other Religion: ____Catholic ____Other Religion: ______

Occupation: ______BAPTISM: Place/Town/State: ______Date (If Known): ______1 ST COMMUNION: Place/Town/State:______Date (If Known): ______CONFIRMATION: Place/Town/State: ______Date (If Known): ______2. NAME: ______Maiden Name (If Applicable) ______Gender ____ Male ____Female Date of Birth: ______Place/Town/State of Birth: ______Relationship: ____Head ____Spouse/Sig.Other Religion: ____Catholic ____Other Religion: ______

Occupation: ______BAPTISM: Place/Town/State______Date (If Known): ______1 ST COMMUNION: Place/Town/State______Date (If Known): ______CONFIRMATION: Place/Town/State: ______Date (If Known): ______Today’s Date: ______Mem. I.D. # ADDITIONAL FAMILY MEMBERS AT THIS ADDRESS: 3. NAME: ______Gender ____ Male ____Female Date of Birth: ______Place City/State of Birth: ______Relationship: ____Child ____Other ______Religion: ____Catholic ____Other Religion: ______BAPTISM: Place/Town/State: ______Date (If Known): ______RECONCILIATION: ___Yes ___No 1 ST COMMUNION: Place/Town/State: ______Date (If Known): ______CONFIRMATION: Place/Town/State: ______Date (If Known): ______4. NAME: ______Gender ____ Male ____Female Date of Birth: ______Place/Town/State of Birth: ______Relationship: ____Child ____Other ______Religion: ____Catholic ____Other Religion: ______BAPTISM: Place/Town/State:______Date (If Known): ______RECONCILIATION: ___Yes ___No 1 ST COMMUNION: Place/Town/State:______Date (If Known): ______CONFIRMATION: Place/Town/State: ______Date (If Known): ______5. NAME: ______Gender ____ Male ____Female Date of Birth: ______Place/Town/State of Birth: ______

Relationship: ____Child ____Other ______Religion: ____Catholic ____Other Religion: ______BAPTISM: Place/Town/State: ______Date (If Known): ______RECONCILIATION: ___Yes ___No 1 ST COMMUNION: Place/Town/State: ______Date (If Known): ______CONFIRMATION: Place/Town/State: ______Date (If Known): ______6. NAME: ______Gender ____ Male ____Female Date of Birth: ______Place/Town/State of Birth: ______

Relationship: ____Child ____Other ______Religion: ____Catholic ____Other Religion: ______BAPTISM: Place/Town/State: ______Date (If Known): ______RECONCILIATION: ___Yes ___No 1 ST COMMUNION: Place/Town/State: ______Date (If Known): ______CONFIRMATION: Place/Town/State: ______Date (If Known): ______