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Name _____________

Date of birth __/__/____

Place of birth: Country ______ State_____________ City ___________

Mother’s name ____________________

Fathers name _____________________

E-mail address _________________________________

Phone number __________________

Driver’s License Number ____________________

Please Answer “Yes” or “No” In The Spaces Provided.

1. ____Are you a Christian?

2. ____ 1Corinthians 7:1 says, “It is good for a man not to touch a woman.” Do you believe the Lord really expects you to keep your hands off a woman until you get married?

3. ____How often do you attend services?

a. Once a week

b. Twice a week

c. Three times a week

d. More

4. ____Do you smoke tobacco?

5. How fast can you run

a. 40 yards ______sec.

b. Two miles ____min.

6. ____Do you chew tobacco?

7. What is your blood type:_______

8. ____Other than a speeding ticket have you ever been convicted of a crime? (If yes, please explain and give dates.)

9. ____To your knowledge do you have any STDs?

10. ____Do you have any tattoos? (If yes tell how many, where, and what kind they are.)

___________________________________________________

___________________________________________________

___________________________________________________

11. ____Do you have any piercings? (If yes tell how many, where, and what kind they are.)

___________________________________________________

___________________________________________________

___________________________________________________

12. ____Have you sinned since you got saved?

13. ____Do you have a valid driver’s license?

14. In 50 words or less, describe what “Don’t ever, ever, touch this girl” means to you.

___________________________________________________

___________________________________________________

___________________________________________________

15. ____Do you own a vehicle? (If so give the make and model and list at least four of the preset stations your radio is tuned to.)

___________________________________________________

___________________________________________________

___________________________________________________

16. ____If the need arose could you take your Bible and lead a person to Christ right now? (If so list some of the Bible verses you might use.)

___________________________________________________

___________________________________________________

___________________________________________________

17. ____Have you consume any alcoholic beverages in the last six months? (If so tell when, where, and how much.)

18. ____Have you taken any medication in the last six months that was not prescribed to you? (If so tell when where and how much.)

19. ____Did Jesus make alcoholic wine?

20. ____Have you smoked marijuana in the past six months?

21. ____Have you, other than by accident, ever hit a woman?

22. ____Would you hit a larger woman if she attacked your girlfriend and you were unable to restrain her otherwise?

23. ____Have you ever been in a physical altercation (a fight) with another man? (If so how many times)

24. ____Do you know CPR?

25. ____Have you ever led anyone to the Lord?

26. ____Do you have any gospel tracts on you right now?

27. ____Do you have any children?

28. ____ Are you a member of any secret society such as the Masons, Shriners, skull and bones, etc?

29. ____Have you ever been married?

30. ____Have you ever been engaged?

31. ____Have you been scripturally baptized?

32. ____Have you ever been accused of rape?

33. ____Are your biological parents still alive?

34. ____Are they married?

35. ____Do you work or go to school? (If yes tell where, for how long, and briefly describe your schedule)

___________________________________________________

___________________________________________________

___________________________________________________

36. How much cash do you have on you right now? _________________

37. What is the longest you’ve ever held a job and where was that?

___________________________________________________

___________________________________________________

38. Other than John 3:16 write out a verse of Scripture from memory.

___________________________________________________

___________________________________________________

___________________________________________________

39. Write out another verse from memory.

___________________________________________________

___________________________________________________

___________________________________________________

40. When did you get saved? __________________________

41. Complete the following sentences:

a. If I were to be shot, the last place I would want to be shot is in the _________

b. If I were to be beaten, the last bone I would want to be broken is ___________

c. The one thing I hope this application does not ask is ______________________

d. In the unfortunate event of my untimely death, I would like my ashes scattered

____________________________________________________

e. My greatest fear is _____________________________________

42. What do you want to be if you grow up? _________________________________

43. Where did you get saved? __________________________

44. Have you ever been fingerprinted? Yes ____ No _____

45. What church do you attend? __________________________

46. Are you a member of that church (if not, please give the name of the church you are a member of) Yes ____ No _____

47. What is the longest relationship you’ve ever been in? _____________________

48. How many times have you been baptized? __________________________

49. Did you get baptized before or after you got saved? __________________________

50. What is your pastor’s name? ___________________

51. (Other than playing Call of Duty) List some of your hobbies:

___________________________________________________

___________________________________________________

___________________________________________________

52. Do you have any identifying marks? (Birthmarks, scars, tattoos etc.) Yes ____ No _____ (if yes please explain and give locations)

53. My dentist is ______________________ City ______________ State _______

I hereby swear that all the information supplied above is true and correct to the best of my knowledge.

Signed ____________________________________ Date __/__/____

Thank you for your interest. Please allow 4 to 6 years for processing.

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