INTERNATIONAL MARRIAGE AND PARTNERSHIP AGENCY since 1996

Questionnaire

Contact Information

First Name *
Last Name *
Email *
Address
City
State
Zip/Postal Code
Country
Do you own or rent your home?
How Long?
Best Contact Phone Number
Best Contact Time
Best Contact Method
Home Phone
Work Phone
Fax
Cellular

Personal Information

Place of birth
Date of birth Month Day Year
Gender
Height Feet Inches
Weight
Hair Color
Eye Color
Education
Occupation
Describe your occupation
Are you self-employed? YesNo
What languages do you speak?
Please list any other languages you speak
About Yourself
(check all that apply)		 I am new to the area
I am too busy to meet people
I do not meet enough quality people
I am not dating anyone seriously now
I am dating someone not compatible
I want to date various people
I desire a steady relationship
I am shy
I am very outgoing
I believe in marriage
I am active
I am very active
I am passive
I am amiable
I enjoy the company of large groups
I have a small circle of friends
I enjoy quiet evenings at home
What community activities do you participate in?
I am
(check all that apply)		 Adventuresome
Ambitious
Demanding
Giving
Reliable
Sexy
Thoughtful
Emotional
Organized
Romantic
Stubborn
Devoted
Creative
Affectionate
Your Athletic Activities Aerobics
Horseback Riding
Boating
Skiing
Cycling
Swimming
Golf
Walking
Jogging
Dancing
Outdoors
Tennis
Other
Please describe any other activities
Do you watch sports? YesNo
Please explain
Do you suffer from any medical condition? If yes, please explain.
About your eating habits Meat
Fish
Natural Foods
Junk Foods
Other
Do you drink alchohol YesNo
Frequency Seldom
Occasionally
Daily
Are you an alcoholic? YesNo
If recovering, how long?
Do you smoke? YesNo
Frequency Moderate
Occasionally
Heavily
If yes, how long?
Have you quit smoking? YesNo
Describe your life goals
You attend church or synagogue Never
Infrequently
High Holidays
Weekly Services
Daily
Twice a week or more
Comment on your religious beliefs and their influences on your life
Ethnic background

Marital Information

Marital Status
If you are separated, divorced, or widowed, how long? Years Months
Have you been married before? YesNo
If yes, how long? Years Months
Do you have children? YesNo
Number of Children
Number of Children living with you
Please describe the sex and ages of your children
Would you like to have children in the future? YesNo
Are you emotionally prepared for marriage?
(1=lowest, 10=highest))
Please comment on your emotional preparedness for marriage

Information About The Compatible Companion You Seek

Age to
Comments on age
Rate their general attractiveness
(1=lowest, 10=highest))
Height Feet Inches
Weight
Hair Color
Eye Color
What physical qualities are you attracted to?
Ethnic Preference
About their athletic activities Aerobics
Horseback Riding
Boating
Skiing
Cycling
Swimming
Golf
Walking
Jogging
Dancing
Outdoors
Tennis
Televised Sports
Other
Describe any other activities
Their occupation Professional
Entrepreneur
Managerial
Technical
Business Person
Self-employed
Retired
Not Important
Their education High School
Junior College
Vocational
University (4 year)
University (4 year)
Ph.D
Professional Degree
Not Important
Other
Other levels of education
Their children No Children
Desires Children
Has Children
Not Important
Comment on children
Their cultural interests Dance
Family Development
Visual Arts
Music
Current Events
Intellectual
Film
Theatre
Other cultural interests
Their musical interests Classical
Jazz
Country Music
Opera
Easy Listening
Popular
Folk/Ethnic
Rock
Comments on musical interests
Views on smoking
Views on alcohol

What are three most important considerations about the person you want to meet?

1.
2.
3.

And finally