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PACEM IN TERRIS ALUMNI TEAM FORM

Please fill in as many fields as possible. Required fields are displayed in red text. Thank you.

First Name Middle/Maiden Last Name
Year of Graduation:
Home Address:
City/State/Zip:
Email Address:
Country/Province:
Home Telephone Number:
Employer:
Job Title:
Work Address:
City/State/Zip:
Work Country/Province:
Work Telephone Number:
Activities, athletics and organizations in which you participated while attending La Roche College:
Please provide Information/Updates on you and/or your family:

Are you Married? Yes No

If Yes, please complete the following:

Spouse's First Name Middle/Maiden Spouse's Last Name
Date of Marriage:
Please enter as MM/DD/YYYY.
Is your spouse a La Roche College graduate?
Yes No

If Yes, please complete the following:

Spouse's Year of Graduation:
Spouse's Employer:
Spouse's Job Title:
Spouse's Work Address:
City/State/Zip:
Spouse's Work Country/Province:
Spouse's Work Telephone Number:

May we include this information in a future issue of the La Roche College Magazine?
Yes No