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BASIC INFORMATION 1. Full legal name: Last First Middle 2. Age 3. Height 4. Weight 5. Eye color 6. Measurements 7. Natural hair color 8. Current hair color: CONTACT INFORMATION 9. Home phone 10. Cell Phone 11. Email GETTING TO KNOW YOU 12. Are you a virgin? Y N 13. If no, how many past sexual partners have you had? 14. Have you ever had a sex change? Y N 15. Do you smoke? Y N 16. Do you use any illegal substances? Y N 17. Do you have kids? Y N 18. If yes, how many? 19. Do you workout? Y N 20. Do you currently have a source of income? Y N 21. If yes, what is it? 22. Do you live on your own? Y N 23. If no, whom do you currently reside with? 24. What kind of car do you drive? 25. Furthest level of education (circle one): High School Some College Associate's Degree Bachelor's Degree 26. Do you have a history of mental illness? Y N 27. Favorite sport & team 28. Have you ever cheated on a boyfriend? Y N 29. Do you cook? Y N 30. Do you have any siblings? Y N 31. What is your religion? 32. What is your political persuasion 33. How many piercings (not including ears) do you have? 34. How many tattoos do you have? 35. What is your current favorite movie of all time? 36. List your three favorite genres of music in order of most favorite to least favorite: 37. What is your idea of a perfect date in three sentences or less? 38. Explain why I should pick you as my girlfriend in one sentence: 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? REASONS I SHOULD PICK YOU RELATIONSHIP BACKGROUND List the details of your past three relationships starting with the most recent. Start Date: End Date: Were you in love? Y N Am I prettier? Y N Sexually active? Y N Reason for breakup: Start Date: End Date: Were you in love? Y N Am I prettier? Y N Sexually active? Y N Reason for breakup: Start Date: End Date: Were you in love? Y N Am I prettier? Y N Sexually active? Y N Reason for breakup: REFERENCES Please supply three references and their phone numbers or email addresses. 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
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