Girlfriend Application
General
Name:
Age:
Location:
Are you employed?
[ ] Yes
[ ] No
Employer:
Education
Highest Grade Completed:
Are you currently enrolled in school?
[ ] Yes
[ ] No
If yes, what is your course of study?
Transportation
Do you have a reliable form of transportation?
[ ] Yes
[ ] No
Do you own your own car?
[ ] Yes
[ ] No
Do you have a license?
[ ] Yes
[ ] No
Family
Do you speak with a majority of your family?
[ ] Yes
[ ] No
Would you sacrifice anything for your family?
[ ] Yes
[ ] No
How often does your family ask you to sacrifice for them?
[ ] Never
[ ] Sometimes
[ ] Often
[ ] Weekly
History
Are you currently in a relationship?
[ ] Yes
[ ] No
Have a majority of your relationships been abusive?
[ ] Yes
[ ] No
Do you speak with any of your ex-boyfriends?
[ ] Yes
[ ] No
If yes, are you “good friends?”
[ ] Yes
[ ] No
How often do you go to the doctor?
[ ] Never
[ ] Sometimes
[ ] Often
[ ] Weekly
Interests
Do you:
[ ] Drink
[ ] Smoke
[ ] Use drugs
Of the previous, what brand/kind do you drink/smoke/use?
How often?
Do you like mushrooms?
Are you in the medical field?
What kind of music do you listen to?
Qualifications
Do you have any special qualifications?
[ ] Yes
[ ] No
If yes, explain:
Please provide at least two references that are not family members:
Name:
E-mail:
Name:
E-mail:
All answers are confidential. I understand that I will not be discriminated based on age, race or sexual orientation. This application or follow-up interviews do not constitute a binding contract for a relationship. Until such contract is put into place either party may end communication or involvement for any reason.
I understand that no single answer will affect my application status.
I hereby affirm that all answers are true, to the best of my knowledge and I have not falsified any information. I understand that falsification of any information on this application could result in termination of contact or involvement.
Name_____________________ Date_____________