1. Full name (You want me to know right now)
2. Age
3. Height
3a. Is it in proportion to a medically acceptable body weight? (Y/N)
4. Eye color
5. Natural hair color
6. Current hair color
7. Have you ever had a sex change?

CONTACT INFORMATION
8. City of Residence
9. Best Contact Phone Number
10. Cell Phone (if different than above)
11. Open to text messages (Y/N)
12. AIM:
13. Email:

FEW WORD ANSWERS
14. Do you have any siblings?
15. What is your religion?
16. What is your political persuasion?
17. Do you have a history of mental illness?
18. Have you ever cheated on a partner?
19. How many piercings (not including ears) do you have?
20. How many tattoos do you have?


MULTIPLE CHOICE Answer the most fitting answer

21. Do you currently have a source of income?
A. Parents, I'm going to school and they help
B. Parents, I'm a trustafarian.
C. I'm unemployed and waiting for my gov't check
D. I got a job til I find a career.
E. I got something pays my bills.
F. I got something that pays my bar tab.

22. Furthest level of education?
A. I dun dropped out of skool.

B. I learned enough to make a living.
C. I went to college and I still work at a gas station.
D. I'm actively furthering my education.

23. What kind of car do you drive?
A. I prefer people power (walk/ ride bike/ rollerskate)
B. I take the bus
C. It gets me to where I need to get to.
D. It gets others out of the mud and snow drifts

24. How many past sexual partners have you had?
A. None
B. Very Select Number
C. A number I personally find acceptable
D. Unacceptable amount

25. Do you smoke? (please choose from following)
NO
A. NEVER EVER EVER!!
B. No/ Not anymore
C. Seldom
YES
D. Only when I drink
E. About one or two a day
F. +5 a day

26. Do you drink? (Please choose from the following)
NO
A. NEVER EVER EVER!!
B. No/ Not anymore
C. VERY Seldom
YES
D. Only at Sunday dinner
E. Just a couple when I pop down to the pub.
F. I get tipsy weekly
G. I get drunk monthly
H. Only on days that end with "Y"

27. Do you have kids?
A. Never Ever Ever
B. Not yet but maybe
C. Yes, they live with me most always
D. Yes, they live elsewhere sometimes
E. Yes, they live elsewhere most always

28. Do you workout?
NO
A. NEVER EVER EVER!!
B. Walking to fridge, tires me
C. I do progressively easier 12ounce curls
D. I just try to eat healthy and avoid exercise
YES
E. Jumping to conclusions, running my mouth, and backstabbing while climbing the corporate ladder is enough for me.
F. Once a month
G. Once a week
H. A few times a week
I. Daily

29. What kind of sense of humor do you have? (Choose ALL that apply)
A. Baby's doing baby stuff.
B. A picture of a cat and a garbled mispelled phrase
C. Knock knock...
D. Knock knock.... Someone just got hit in the balls
E. Knock knock... That's the sound Knoxville's balls made when he got tasered.
F. I like a witty turn of phrase
G. A man walks into a bar....
H. A Kike, A Spic and a Dothead walk into a bar
I. A dead baby walks into a bar....

30. Whom do you currently reside with?
A. By Myself
B. With the parents/ parent types
C. With a roommate or two
D. My kids.
E. My cat army

31. Do you cook?
A. I burn water
B. I stop at toast and coffee
C. Frozen Dinners
D. I can pair my EZ Mac with some Tuna Helper
E. I can follow a simple recipe
F. I can take raw veggies and meat scraps to make a tasty stew
G. The Iron Chef has me on speed dial.

SHORT ANSWER (CHOOSE 2)
32. Favorite book & subject matter?

33. If you were an animal, what would you be and why?


34. Do you have any irrational fears? How irrational?

35. What is your current favorite movie of all time?

36. List your favorite few genres of music:


SHORT ESSAY (Please do ALL)
37. What is your idea of a perfect date in three sentences or more?


38. Explain why I should pick you as my partner:

39. List any special skills that you may have that are relevant to this position:

40. What do you want out of a relationship, specifically one with me?

RELATIONSHIP BACKGROUND
List the details of your past three relationships starting with the most recent.
Duration:
Were you in love?
Reason for breakup:

Duration:
Were you in love?
Reason for breakup:

Duration:
Were you in love?
Reason for breakup:

CERTIFICATION
I hereby certify that the information given by me in this application is true to my knowledge and I give you the authorization to verify it using any means you deem appropriate. I understand that by filling out this form and submitting it for review does not guarantee that I will be chosen.

Date Applicant Signature

Do not write below this line, this area will be used to take notes when conducting interviews.
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