Application

To reserve a place on a weekend, please separate this application form and mail it with payment check of $200 (made payable to Catholic Engaged Encounter).

Catholic Engaged Encounter, c/o Randy and Judy Bergman, 79 Cedar St., Akron, NY 14001

Confirmation of weekend reservation will be mailed within 7 days of receipt of completed application and deposit.

Questions call: (716) 542-4168

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His Name			Her Name
His Address			Her Address
City, State, Zip			City, State, Zip
His Phone			Her Phone
His Age			Her Age
His Religious Affiliation			Her Religious Affiliation
Referred By		Wedding Church/Town
Wedding Date		Priest Performing Ceremony
Any special needs
Weekend Date Choices	1st)			2nd)
(Please Circle One) Send Future mailings to: Him / Her