Questionnaire

“This one page questionnaire will remain private and confidential and should take approximately 10-15 minutes to complete.”

Tell Us About Yourself:

Legal Name:

Preferred Name:

Address:

City, State, Zip:

Phone:

Email Address:

Drivers License:

Occupation:

Employer:

Marital Status: Never Married Separated Divorced Widowed

If married, how many times:

If married, for how many years:

Do you have any children? Yes No

How Many?

Ages:

Do you desire more children? Yes No Maybe

Are you willing to adopt? Yes No Maybe

Age:

Birthdate:

Eye Color:

Hair Color:

Height:

Weight:

Where were you born and raised?

Education Level:

School(s) & Degree(s):

Describe Your Level of Practice:

Political Party: Republican Democratic Independent Not Political

Describe yourself:

Describe your work schedule:

Why are you considering our matchmaking service to help you?

Describe your background:

Describe your relationship goals:

What are you passionate about?

Do you have any special talents or accomplishments?

How do you like to spend your free time?

Do you participate in any sports, activities, or hobbies?

Do you workout? Yes No Occasionally

If yes, how many times a week?

What is the status of your health? Excellent Good Fair Poor

Do you have pets? Yes No

Do you have any pet allergies? Yes No

Do you smoke? Yes No

Distance willing to travel:

Has a restraining order ever been filed against you? Yes No

Have you ever been convicted of a felony? Yes No

YOUR MATE

Describe the type of mate you would like to meet?

What are the most important traits for your mate to possess?

Are there any deal breakers or things you will not tolerate in your mate?

Physical Preference:

Desired Age Range:

Desired Height Range:

Do you prefer your mate with:
Full Time Career Works Part Time Retired Does Not Matter

Would you date someone with children? Yes No Maybe

If maybe please explain:

Is his/her religion important? Yes No Maybe

Is political party important? Yes No Maybe

Is smoking acceptable? Yes No Maybe

What is the best time for us to contact you?

How did you find out about us?

By executing this questionnaire, you declare all of the information stated to be true and correct and you agree to be bound by the terms of use set forth below.

Questionnaire

Tell Us About Yourself:

YOUR MATE

For More Information