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*Name: |
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Birthdate: |
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Address: |
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*E-mail: |
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*Home Phone: |
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Work Phone: |
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Marital Status: |
Single
Divorced
Widowed |
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Children: |
Yes
No |
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Smoker
Non-Smoker |
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Pet Allergies: |
Yes
No |
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Occupation: |
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Education: |
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Religious Preference: |
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| What are you looking for? |
Lots of dates |
Steady Relationship |
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Marriage |
Friendship |
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Other
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| How often do you date? |
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per week
per month |
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haven't dated for
weeks |
| Desired age range: |
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to
years old |
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| What five characteristics are you looking for in another person? |
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1:
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2:
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3:
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4:
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5:
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| What are your five favorite activities? |
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1:
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2:
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3:
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4:
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5:
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| I am interested in: |
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Introduction Services |
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Stepping out Newsletter & Lectures |
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The Caribbean Cruise |
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Upcoming Singles Weekends |
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| Other Comments: |
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| Today's Date: |
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