Please Describe Yourself

First Name: Last Name:
Address:
City:
State:
Zip Code:
Day Time Phone: ( ) - Type:
Evening Phone: ( ) - Type:
Best Time to Call:
Email Address:
Sex:
Age:
Height: Inches:
Weight:
Education:
Occupation:
How Long:
Annual Income:
Marital Status : How long :
Children: How many :
Custody:
Still Wanting Children :
Religion:
Smoke:
Drink:

My Current Social Situation Is:
(please check all that apply)

I'm new to the area I don't want to settle for second best
I don't feel comfortable asking people out Safety concerns me
I'm really busy with work I'm tired of people playing games
I meet a lot of people, just not the right type I'm a single parent
I don't like the bar scene I'm very selective of whom I will date
Are you moving within the next 6 months?
My goal is:

About the person you are seeking:

Age range: to:
Smoking:
Drinking:
Education:
Occupation:
Location:
Athletic Interests:
Appearance:
Religion:
How important is Religion when selecting a companion?
Marital Status:
Children:

Personality Traits you would like in a companion:
(please choose from the following)

Honest Romantic Kind Friendly
Respectful Enthusiastic Witty Thoughtful
Affectionate Spiritual Genuine Passionate
Intelligent Ambitious Physically Fit Outgoing
Compassionate Energetic Health Conscious Fun
Organized Loyal Happy Dependable
Level Headed Grounded Neat Modest
Funny Goal Directed Determined Perceptive
Good Listener Spontaneous Successful Calm

Other:
(please choose from the following)

What would you like to know first before going out on a first date?

Hobbies Religion Wants Children
Athletic Interests Cultural Interests Looks
Goals Occupation Education Level

What are some of the problems you have had with previous companions?
(Things you definitely want to stay away from!)

Over Jealous Incompatibility Different Goals
Infidelity Financial Management Different lifestyle
Too Controlling Different Interests Lack of affection
Trust Lack of commitment Lack of communication
Moody Different Values Sexual Incompatibility
Self Image Different religious beliefs Parental Viewpoints

How are you meeting people now?

Friends/Family Work
Bars/Nightclubs Church
Online
 Chance

What, if any, issues did you encounter when using an online dating site?

Inaccurate Profiles Not everyone was single
Misleading Photos People wanting to play games
Safety Concerns No singles in my local area


Questions you have for us:

How comfortable do you feel about speaking with a relationship expert?

How did you hear about us?