Husband's full name: _____________________________
Date and Place of Birth:_________________________
Parent's names:__________________________________

Wife's full name: _________________________________. **Use maiden name for all females.
Date and Place of Birth: ___________________________
Parent's names: ____________________________________

Year of marriage: _____________

List names of children and year of birth if known:
_____________________________ ________. _____________________________ ________
_____________________________ ________. _____________________________ ________
_____________________________ ________. _____________________________ ________
_____________________________ ________. _____________________________ ________
_____________________________ ________. _____________________________ ________
_____________________________ ________. _____________________________ ________
_____________________________ ________. _____________________________ ________

Place of Birth: TOWN IN ITALY: ________________________PROVINCE or Region:______________________________
Be sure to fill in the name of province, as there may be more than one town in Italy by the
same name. If you only know the province and not a specific town but have names and dates you must use Form C.

THANK YOU FOR YOUR ORDER. Please enclose a self-addressed, stamped envelope. ALLOW about 9 WEEKS.

PAYMENT METHODS: Credit Card: (USA only) VISA, Mastercard, American Express, Discover. (Print Clearly !)
Expiration date: (___ /____ Security Code __ __ __ __
Account Number: ________________________________ Authorizing Signatue: ______________________________________

Personal Check payable to: "Pallante Center", or use Paypal.com (use debhill@capital.net). Outside USA: Int'l Bank check or Int'l Postal money order.

Mail this form to: