Dating Survey

If you fill out the form below it gives me a start in learning about you so that I can better know the type of person that you want to meet. Safety and Security: Under no circumstances would I give out this information without explicit permission and understanding from you.

First name *

Last name *

Address *

City *

State *

Zip Postal Code *

Telephone Number *

Email Address *

Your comments

Are you single, divorced, or widowed?

What is your educational background?

What is your age?

What is the age range of the people you will date?

Do you smoke and will date a smoker?

Do you have children? Will you date someone who has children?

How far will you travel to meet a match?

What is your religion and how important is religion to you?

How much do you drink per week?

Is physical appearance important to you? on a scale of 1-10?

What percent of interests do you want in common with your match?