Thank you for your interest in dating me. Due to the high volume of interested applicants, I will not be able to reply to all. Allow four to six weeks for processing. A $10 processing fee may be imposed for incomplete or illegible applications.
Applicant’s Full Name______________________
Applicant’s Nickname(s) _____________________________
Age _____
Height_____
Weight______
Occupation _____________________________
Vision Score _________
Credit Score__________
Please state specific reason(s) for your last breakup.
Has a restraining order ever been filed against you?
Have you ever been convicted of a felony?
Do you currently have a driver’s license?
Have you ever been married?
Have you ever undergone sexual reassignment surgery?
Are you currently taking any medications?
Do you have piercings/tattoos? Please specify where and how many.
Do you floss your teeth?
Do you wax/shave your chest?
Do you wax, shave, or pluck other regions of your body?
Do you partake of recreation drugs? Which ones and how often?
Do you smoke cigarettes/cigars?
How many drinks do you consume on average on a weeknight?
How many drinks do you consume on average on a weekend?
What time do you wake up on weekends?
Which side of the bed do you prefer to sleep on?
How often do you travel for work?
How much time do you spend looking in the mirror per day?
Does it take you longer than fifteen minutes to get ready?
How many “psycho” ex-girlfriends do you have?
How many exes are you still hooking up with?
When was the last time you had sexual intercourse? ___ a few hours ago ____a few days ago ____a few months ago ____a few years ago
How many porn subscriptions are currently in your name?
Can you provide written documentation that you are free of STDs?
Do you have any sexual dysfunctions that cannot be treated by a doctor?
How many one night stands have you had in the last six months?
On average, how many women do you sleep with at one time?
Please specify all fetishes.
Are you a giver (and not necessarily in the financial sense)?
Check applicable sleep conditions: ___ sleep apnea ___bed wetting ___ sleep-walking ___sleep-talking ___random thrashing ____cover hogging
Do you have a reputation in the San Francisco Bay Area? If so, please specify.
Have you ever dated any of my friends or family members?
Have you ever been suspected of cheating on a former girlfriend?
Will you dance?
Do you own cats?
Do you like garlic?
Do you have children?
Do you like children?
Do you live alone or with a roommate?
Do you have a good relationship with your mother?
Is she prone to mood swings or currently taking anti-depressants?
Do you wear cologne? Please spray this form with the kind you are likely to wear on a date.
What is your preferred mode of communication? ___ text ___phone ___email ___IM ___Post-It note ____social networking site
Describe your perfect first date.
Please attach one baby picture, three references, and a copy of your current immunization records.
I ATTEST THAT THESE ANSWERS ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE UNDER PENALTY OF PERJURY.
X _______________________________________
