First Name Last Name Street Address City State VA DC MD DE PA NJ NY CT GA AL FL Zip Email Home Phone Cell Phone Work Phone Occupation How long? Tell Us About the Person You'd Like to Meet Age From to Does not matter Smoke Please Select Yes No Does not matter Appearance Please Select Very Attractive Attractive Average Does not matter Children Please Select Has Children No Children Desires Children Does not matter Interests You Would Like To Share: Please select Cultural Activities Travel Spectator Sports Dining Out Outdoors Movies All of the Above Does not matter Education High School Some college Degree Advanced degree Body Type Small frame Medium frame Large frame Does not matter Other Qualities Tell us about yourself Age Gender Male Female Planning to Move in the Next Six Months? Yes, where? No My Primary Social Goal is Casual dating Long term relationship Marriage My Relationship Status is Please Select Never Married Separated Divorced Widowed My Social Situation is as Follows I am new to this area I am too busy to look for someone I do not meet enough quality people Not dating anyone I would consider for a long-term relationship Dating someone who does not want what I want in a relationship I have not been dating Recently ended a relationship My Annual Income is Please Select Under $15K $15K to $25K $25K to $35K $35K to $50K $50K to $75K $75K to $100K Over $100K Education Please Select High School Some college Degree Advanced Degree J.D. M.D. The Best Time to Reach Me is Please Select Afternoon Evening Anytime How Did You Hear About Options? Please Select Member Friend Search Engine Advertisement Yellow Pages Sign Mailer What Encouraged You to Fill Out this Survey? How Long Have You Considered a Service? Please Select Just Recently 3 to 6 Months 6 to 12 Months 1 Year or More
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