Make Me A Match Inc. - Application

Please fill the following profile out to the best of your knowledge. If any answers to questions are unknown or do not apply, place the letters "NA" (meaning not applicable).

At the end of this process, you will be asked to read the Terms of Use Agreement carefully, and place checkmarks next to the appropriate boxes showing your agreement to the application and Terms of Use. Please sign your name in the Application/Terms of use agreement box, pay the $9.99 mandatory registration fee , and YOU ARE ONE STEP CLOSER TO MEETING YOUR SOUL-MATCH AND SHARING THE REST OF YOUR LIFE WITH SOMEONE SPECIAL. LET THE PROCESS BEGIN!


* Required Fields
* Create a User Name:
* Create a Password:
* Confirm Password:

* First Name:

* Last Name:

* Address:

(including suite #, if applicable)

* City:

* State:

* Zip:

Have you moved within the past 12 months:

Yes No

If you answered yes, please indicate your previous residence Address:

City:

State:

Zip:

* Home Phone:

* Cell Phone:

* Email:

* Confirm Email:

* Birthdate:

*Social Security Number(Please put the sum of the first and last digit of your social security number here):

Example: If your social security number is 123-45-6789, the sum of the first and last digits would be (1 + 9 =) "10".

Height:

Weight:

Eyecolor:

Hair color:

* I am a Male looking for a	Female Male
* I am a Female looking for a	Male Female

*Photo:

upload a full length color photo
(216 pixels x 360 pixels) -width x height
.JPG or .PNG or .GIF -file types

Current Occupation:
Name of Employer:
Address:	(including suite #, if applicable)
City:
State:
Zip:
Business Phone:
Ext:
Employed at this company for:	years
Retired Not Working Out of Work Independently Wealthy

1) Please indicate where you grew up:

* 2) What is your level of education:

High School
Vocational School
Jr. College
College;Concentration of Study:

Post Graduate
None of Above; �Please explain�

* 3) Please list any degrees:

Technical or Vocational Certification
AAS
Baccaluarate
Masters
Ph.D
Other:

* 4) What is your income level:

$20,000-$40,000 $40,000-$60,000
$60,000-$80,000 $80,000-$100,000
$100,000-$200,000 $200,000 or above
Other

* 5) Would you prefer to date someone who:

Makes an income equal to yours
Makes an income more than yours
Makes an income less than yours
Income not important

* 6) What is your marital status:

Single
Separated
Divorced months years
Widowed

* 7) What are your dating goals:

Casual
Long term relationship
Long term relationship leading to marriage

* 8) Do you smoke:

Yes
No
Occasionally

* 9) Would you date someone who smokes:

Yes
No
Unimportant

* 10) Do you use drugs socially:

Yes
No
Occasionally

* 11) Do you drink alcoholic beverages:

Yes
No
Occasionally

* 12) Do you have children:

Yes
No

If yes, how many:
Number living with you:
Ages:

* 13) Do you want children:

Yes
No
Open

* 14) Would you prefer to date someone who:

Has children
Has no children
either one

* 15) Do you have pets:

Yes
No
If yes, please specify:

* 16) Will you date someone with pets:

Yes
No
either one

* 17) Are you allergic to pets:

Yes
No
If yes, please specify:

* 18) Would you meet people of different ethnic backgrounds:

Yes
No

19) What is your ethnic preference: (Optional)

Caucasian	Oriental
African American	Latino
European	Indian
Middle Eastern	Other

20) What are your political views:

Liberal
A-Political
Socially Liberal
Fiscally Conservative
Other

21) What is your religious preference: (Optional)

22) Do you want your partner to be of the same religion:

Yes
No
Unimportant

23) What personality traits best describe you:

Outgoing Quiet Refined	Shy Romantic Sensual
Independent Confident Spiritual	Ambitious Sophisticated Controlling
Open Communication Compassionate Moody	People Orientated Perfectionist Passionate
Trusting Athletic Intense	Free Spirited Professional Carefree
Supportive Adventuresome Sensitive	Calm Conservative Religious
Sense of Humor Creative High Morals	Positive Health Conscious Cultured
Spontaneous Organized Emotional	Optimistic Extrovert Punctual
Introvert Flexible Friendly	Structural Happy Compulsive
Tidy High Energy Risk Taker	Argumentative Educated
List Other Traits:

24) What are your recreational activities:

Travel Golf Dancing	Jogging Boating/Sailing Aerobics
Dining Out Body Building Reading	Motorcycling Watching Television Swimming
Theater Snow Skiing Movies	Water Skiing Concerts Roller Blading
Musicals Hiking Opera	Tennis Volunteer Work Snorkeling
Politics Bicycling Camping	Gardening Cooking Museums
Jazz Horseback Riding	List Other Interests or Activities:

25) How much space do you require in a relationship:

I need a small amount of "me" time — that satisfies me.
as long as I have one day a week to do what I want, I'm happy.
at least 2 days a week to do what I want.
I don't require any space in a relationship, but if my partner needs some, I am agreeable to that.
Other, Please Explain

26) What form of reading material do you prefer:

Newspaper
Trade Journals
Magazines
Fiction
Non-Fiction
Other

27) Do you watch TV - if so, what kind of programs do you prefer:

News
Sports
Comedy
Classics
Drama
Romance
Reality
History
Other

28) Do you enjoy the movies, if so, what kind of movies do you prefer:

I only watch movies that I can bring home from the video store
classics
romance
military
espionage
adventure
comedies
horror
Other

* 29) Do you have any health problems:

Yes
No
If Yes, explain:

30) Do you have any special dietary preferences or eating habits:

Yes
No
If Yes, explain:

31) Do you exercise:

Yes
No
If Yes, how often:

32) Do you travel:

Yes
No
If Yes, how often:

33) Where do you enjoy traveling:

Local
U.S.
Worldwide

34) What is your favorite travel location:

35) List personality traits most important to you in a mate:

36) List personality traits most NOT compatible with you:

37) Describe your ideal mate:
(Approximate ranges)

Age:
Height:
Weight:
Hair color:
Eye color:
Children:
Personality:

38) Preferred Geographic Location:

Silicon Valley
Santa Clara
Sunnyvale
San Jose
Fremont
Mountain View
Other:

39) Have you been involved in a dating service before:

Yes
If Yes, explain:

40) Is there anything you would like done differently:

41) How did you hear about Make Me a Match?

Friend
Advertisement
San Jose Metro
Wave
Jewish Bulletin

42)Are you interested in finding out more about Rayna Lumbard, LMFT, our master relationship coach, for your Heart2Heart (H₂H) success?

Yes
No
maybe

43) Are you interested in utilizing the services of our fashion consultant, Mary Jones?

Yes
No
maybe

* I expressly grant Make Me A Match, Inc. permission to verify my identity.
* I declare under Penalty of Perjury under the Laws of the State of California that the foregoing is true and correct.
* I have read the Terms of Use Agreement carefully and acknowledge and agree to its terms and conditions by signing and dating this agreement.

* Signature: * Date:

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