Name
Gender	Male Female
Age
Status	Single Divorced Separated Widowed
Phone
Email
Best time to contact you
Education	High School Some College College Graduate Post Graduate
Occupation
Typical Work Week 40 hours 50+ hours Nights and/or Weekends
Do You Smoke? Yes No
What is your current social situation? Dating various people Not Dating New to area Too busy to meet others Recently ended a relationship
What are your relationship goals? Make new friends Casual Dating Committed Relationship Marriage
How did you hear about us? Radio TV Newspaper Search Engine Referred by friend Word of mouth Brochure / Flyer Yellow Pages
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