Email:

First Name:

Middle Name:

Last Name:

Hair Color:
Blonde Brown Red Black Other

If you selected 'other' - please clarify: 

Eye Color:
Blue Brown Green Other

If you selected 'other' - please clarify: 

Your Body Type:
Petite Thin Athletic Average A few extra pounds Curvy Heavy

Do you have any conditions, medical or otherwise, that may affect the matchmaking process (this can include STDs, restrictions, allergies, disabilities or special needs)?:
Yes No Other

If you selected 'yes' or 'other' - please clarify (Optional):

Will you date an individual that may have known conditions or restrictions, medical or otherwise (this can include STDs, restrictions, allergies, disabilities or special needs)?:
Yes No Other

If you selected 'yes' or 'other' - please clarify (Optional):

Enjoyments/Hobbies:

Vices: (Alcohol, Smoking, Recreational Drug use, etc.):

Are you the Life of the Party or a Wallflower?:
Life of the Party Wallflower

Are you a sensitive person?:
Yes No

Are you good at following rules and guidelines?:
Yes No

Do you like our current President?:
Yes No Other

Please include the President's name, and if you selected 'other' - please clarify:

Five Favorite books, movies, and/or TV shows:

Favorite type(s) of music:

Are you an Omnivore, Vegetarian, Carnivore, Pescatarian, etc.? Favorite foods?:

Do you have pets?
Yes No

If you selected 'yes' - what type?:

Tell us about you! What are some of your positive and negative traits?:

Who are your three 'celebrity crushes'?:

When was your last relationship?:

If separated or divorced, how is your relationship with your 'ex'?:

Describe your last 'ex':

What are your five 'must-haves' in a relationship?:

What are your five 'deal breakers' in a relationship?:

Tell us all about your (Potential or Existing) mate - physically, mentally and emotionally:

Dating career preferences (homemaker, student, executive, entrepreneur, etc.):

Dating education preferences (you can select multiple):
 High-School  Associates  Bachelors  Masters  PhD  Doctorate  No-Preference

Dating personality preferences (extrovert, introvert, etc.):

Dating income level requirements (you can select multiple):
 Under $25,000  $25,000-$50,000  $50,000-$100,000  $100,000-$150,000  $150,000-$250,000  $250,000-$1,000,000  Over $1,000,000  Over $5,000,000  No Preference

Dating height range:
Minimum Height: 4' 4' 1" 4' 2" 4' 3" 4' 4" 4' 5" 4' 6" 4' 7" 4' 8" 4' 9" 4' 10" 4' 11" 5' 5' 1" 5' 2" 5' 3" 5' 4" 5' 5" 5' 6" 5' 7" 5' 8" 5' 9" 5' 10" 5' 11" 6' 6' 1" 6' 2" 6' 3" 6' 4" 6' 5" 6' 6" 6' 7" 6' 8" 6' 9" 6' 10" 6' 11"    Maximum Height: 4' 4' 1" 4' 2" 4' 3" 4' 4" 4' 5" 4' 6" 4' 7" 4' 8" 4' 9" 4' 10" 4' 11" 5' 5' 1" 5' 2" 5' 3" 5' 4" 5' 5" 5' 6" 5' 7" 5' 8" 5' 9" 5' 10" 5' 11" 6' 6' 1" 6' 2" 6' 3" 6' 4" 6' 5" 6' 6" 6' 7" 6' 8" 6' 9" 6' 10" 6' 11"

Dating location range:
Within:   50 Miles  100 Miles  200 Miles  500 Miles  My State  Anywhere

Will you date someone that lives more than two hours from you?
Yes No

Are you willing to relocate for Love?
Yes No

Please list all of the dating sites you have used:

What Services are you most interested in (you can select multiple):
 Love Introductions/Matchmaking  Date Coaching  Relationship Coaching  Online Dating Profile Management  Ex Services  Joining our Dating Lovebase

Why do you want to work with us?:

Your Facebook link:

Other Social Network links:

Anything else we should know about you, your ex, your love or your mate? Hold nothing back!:

Clear