Name:    Phone number:

Email Address:

City that you live in: Where did you hear about us?

Occupation:      Annual Income select Under $50,000 $50,000-$100,000 $100,000-$200,000 $200,000-$500,000 $500,000-$1,000,000 $1,000,000 +

Education (Univ./College, Degrees):

Birth Date:    Age:       I am a match for VIP Client # 1 2 3 4 5 6 7 8 9 10

What age are you comfortable dating?

Height:     Weight:    Eye Color:     Hair Color:

Your goal is: To date a lot     Have a committed relationship    Marriage

Ever married? Yes No    Divorced since:

Drink? Yes No    Smoke? Yes No     Date smoker? Yes No

# Of children that you have     Ages?

Wish to have a child? Yes No Maybe     Will you date someone with a child? Yes No Maybe

Please list any languages you speak besides English?

Religious Affiliation, (practicing/semi practicing)?

Religious Preference:

Are you close to your family? Yes No

Do you like animals Yes No    What pets do you have?

Any allergies to animals?

Where were you born/raised?    How long have you lived in CA?

Do you play any Sports? Please List:

Enjoy watching sporting events? (Favorites):

Enjoy the Arts? Yes No

Live theatre    Movies     Going to museum/galleries

Live Music       Favorite Music:

Like to Travel? Yes No

Where have you traveled in the last 2 years that you really enjoyed:

Would like to travel to:

Are You Artistic?    Play Instrument/Sing?

Do you enjoy dancing? Yes No    What Type?

Please list any other interests and hobbies:

A short description of how your friends might describe you:

Describe the person you'd like to meet: