APPLICATION FOR DATING (PDF)

APPLICATION FOR DATING / RELATIONSHIP
Date ________________________
Directions: Type or print in blue or black ink. Answer all questions which are applicable. Please do not state “See Resume”.

Last Name

PERSONAL INFORMATION
First Name

Address

City

Phone:
Height:
Facebook Name:
# of Children:

Middle

State

Zip

Ethnicity:
Weight:
DOB:
# of Baby Fathers:

DATING/RELATIONSHIP INFORMATION

Are you dating, seeing, fucking, or in a relationship with another person at the present time? ________ If
yes, please complete the information below
How many individuals are you currently (Past 30 days) dating, seeing, fucking or in relationship with?
________

Person(s) Name(s) & Number(s): Use separate sheet if needed.

1. What was the length of your longest relationship?
2. How many total relationships have you been in past the age of 21?
3. Can you show legal proof of your age?
4. Have you ever been accused of being mentally or emotionally unstable?
5. Have you ever been accused of being crazy?
6. Have you ever destroyed, vandalized or defaced the personal property of any ex-lover?
7. Have you ever been accused of domestic violence?

A yes answer to questions 4-7 does not necessarily disqualify an applicant.
If yes to numbers 4-7, please explain:

EDUCATION

Did you graduate high school?
If “No” do not proceed any further with this application. If “Yes”, continue.
Are you pursuing of have you completed higher education?
Current level of education?

SKILLS

Please list skills that which you feel will make you a good candidate to date or become seriously involved
with. Ex: I cook, I sew, I like boxing, I have all my teeth, etc.

REFERENCES
Please list the names and number of the last 3 individuals you were in a relationship with for 120 days or more

Name:
Name:
Name:

Ph#:
Ph#:
Ph#:

I certify that all statements made are true and correct to the best of my knowledge. I authorize
investigation of all statements herein recorded. I release from liability all persons and organizations
reporting information required by this application.

Signature:

Date: