GEREJA KATOLIK KEUSKUPAN SURABAYA

PAROKI SANTO MATEUS

Jl. Letjen Sutoyo No. 78 Telp. 0354 - 391188
PARE 64211 – KEDIRI – JAWA TIMUR
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FORMULIR PENDAFTARAN KATEKUMEN

Wilayah : _________________________
Stasi/Lingkungan : _________________________

A. DATA PRIBADI KATEKUMEN

1. Nama diri : .......................................................................................................
2. Nama baptis yang dipilih : .......................................................................................................
3. Tempat / tgl. lahir : .......................................................................................................
4. Pendidikan terakhir / sekolah : .......................................................................................................
5. Pekerjaan : .......................................................................................................
6. Agama yang dianut sebelumnya : .......................................................................................................
7. Alamat rumah / Telp. / HP : .......................................................................................................
8. Wilayah : .......................................................................................................
9. Lingkungan / stasi : .......................................................................................................

B. DATA ORANG TUA

1. Nama ayah : .......................................................................................................
2. Agama : .......................................................................................................
3. Pekerjaan : .......................................................................................................
4. Alamat : .......................................................................................................
1. Nama ibu : .......................................................................................................
2. Agama : .......................................................................................................
3. Pekerjaan : .......................................................................................................
4. Alamat : .......................................................................................................

C. GURU AGAMA YANG MEMBIMBING

1. Nama : .......................................................................................................
2. Mulai mengikuti pelajaran/hari- tgl. : .......................................................................................................
3. Tempat pelajaran : .......................................................................................................

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Mengetahui
Ketua Wilayah Ketua Lingkungan / Stasi ______________

______________________ ________________________

Catatan : Formulir ini dibuat rangkap 2 ( dua ) untuk arsip lingkungan dan Sekretariat Paroki.