HOUSEHOLD TYPE
INSTITUTIONAL 2
P-I
SERIAL NUMBER O f PERSON:
P-2
NAME:
P-3
RELATIONSHIP TO HEAD OF HOUSEHOLD:
o2
(Print)
ay/month/year,
I f d a t e unknown,
e n t e r e s t i m a t e d age,
/
I
-
/
/
e d or’ D i v o r c e d
1
2
-
3 P-8
Congregational Christian
Catholic
Methodist
- Roman
4
5
6
-
LDS (Mormon)
S e v e n t h Day A d v e n t i s t
Other Religion
CITIZENSHIP:
( a ) F o r W e s t e r n Samoa c i t i z e n s e n t e r c o d e
7
-
No R e l i g i o n
‘00’
i t e F a l p u l e D i s t r i c t and V i l l a q e
P-7 3 SCHOOL ATTENDANCE:
O - No
-?
- Yes
l
P-14 EDUCATIONAL ATTAINMENT:
W r i t e h i g h e s t c l a s s of
formal education completedo
most t i m e
-t
-
Employer
business
A,
EMARKS:
or s e r v i c e c a r r i e d o u t by t h e i n s t i t u t i o n ,
Number o f c h i l d r e n b o r n a i i v e ( e x c l u d i n g s t I L l b i p t s and a d o p t e d
childsen) o
umber o f c h i l d r e n b o r n a l i v e -that a r e s t i l l L i v i r t g ( e x c l u d i n g a d o p t e d
I f n o t p r e s e n t d u r i n g census
a n d V i l l a g e w ere p r e s e n t at t h a t t i m e ,
F /n
O
.I
O
-i
P -1
P-2
P-3
P-4
P-5
P-6
'-8
P-9
P-10
P-I I
P-I 2
P-" 3
8-2
NAME:
(Print)
3
-
2
-
Separated o r Divorced
Married
,
e s t e r n Samoa c i t i z e n s e n t e r code qOoOp
t r i c t and V i l l a g e
r s and t h o s e n o t
-9
W r i t e h i g h e s t c l a s s o f Fopma
P-15 TYPE OF ACTIVITY:
2
-
-
Yes
I
education completedc
(Refer t o attached sheet)
Employee
OF INDUSTRY, B i i s m E s s OR S E R V I C E :
ate type o f i n s t i t u t i o n i n whic
s i n e s s or s e r v i c e c a r r i e d o u t b
e or kind of i
EN EVER BORN A L I V E :
a l i v e ( e x c l u i n g s t i l l b i r t h s and adopted c h i l d r e n ) ,
d r e n b o r n a l i v e t h a t ape s t i 1 l i v i n g ( e x c l u d i n g a d o p t e d
h/year
of b i r t h o f l a s t live b o r n c h i l d ( e x c l u d i n g a d o p t e d
children)
REMARKS:
I-F r i o t p r e s e n t dup.
a n d V i l l a g e where
g c e n s u s moment, s t a t e F a i p u
esent at t h a t t i m e ,
F/D
Vil,
*
-
o
occ
4-2
e
2
eta
2
2
---%
o:
o
o
Y/
L LY
V