| 1 | Name (first/last) : | |
| 2 | Address | |
| 3 | City | |
| 4 | State |
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| 5 | Zip/Postal Code: | |
| 6 | Country |
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| 7 | Do you own or rent your home?: |
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| 8 | Best Contact Phone Number: | |
| 9 | Best Contact Time: |
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| 10 | Best Contact Method: |
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| 11 | Your Email | |
| | please re-type your e-mail: | |
| 12 | Your birthday |
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| 13 | Hair Color: |
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| 14 | Eye Color: |
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| 15 | Body Type: |
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| 16 | Height: | feet inches |
| 17 | Languages Known: | |
| 18 | Ethnicity (choose all that apply) |
Native American
Middle Eastern
White / Caucasian
East Indian
Asian
Black / African descent
Latino / Hispanic
Islander
Other
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| 19 | Religion : | |
| 20 | Occupation: |
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| 21 | Education: |
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| 22 | Current Income Level: |
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| 23 | How much of a financial investment are you prepared to make to find your desired companion?:
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| 24 | Drinking Behavior: |
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| 25 | Smoking Behavior: |
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| 26 | Relationship Status: |
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| 27 | Have Children: |
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| 28 | Want Children: |
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| 29 | About Me |
| | | |
| 30 | My favorite types of music are: (choose all that apply) |
Alternative
Rock
Pop
Rap/Hip Hop
Electronic / Techno
Classical
Jazz
Blues
Latin
Country & Western
Folk
Christian / Gospel
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