Valentine's Day Application

Contact Information
Name: _________________________________
Address: ________________________________
Phone #: ____________________________
Cell phone #: _______________________
Screen Name AOL: ___________________________ MSN: ___________________________
Yahoo: __________________________
E-mail address: ____________________________________

Vital Statistics
Height: ______________ Weight: _______________
Eye color: _________________ Hair color: _________________
Hair style: _______________________

Measurements
Chest: ___________ Waist: ___________ Booty: ___________
6-pack? Yes / No
Tattoos? Yes / No If yes, indicate what and where.

Piercings? Yes / No
If yes, indicate where and why:

For verification purposes, full frontal and rear photos of self are required. Attach photos with
application (unless submitting application in person).

Psychological History
Personality Description:

Mental Illnesses, Psychoses, Conditions? Yes / No

If yes, list all as well as any psychologists, therapists, and other professional support personnel
you were in the care of.

Questionnaire
Ideally, where would you take someone on Valentine's Day?

Sports: Participation or watching?

How often? _____________________
Flexibility rating: 1-10 (10 is best): ___________
Virgin? Yes / No
*If no, how many partners: ___________

Wildest thing You’ve ever done sexually:_____________

Drink alcohol? Yes / No
*If yes, indicate how often and the quantity:

Smoke or chew? Yes / No

*If yes, indicate which and what kind:

Messy or clean? ______________________

Adventurous or timid? _________________________
How often do you shower? _________________________
How many relationships have you been in? ______________________________
*Note: Even those relationships that lasted only a day MUST be included.
Current major/profession: ___________________________________

Failure to disclose any and ALL mental illnesses, psychoses, and conditions, as well as having
the personality of a pissed-off, hormone-enraged purple-back gorilla is grounds for immediate
termination of the "date". The undersigned has truthfully answered all of the above questions or
has at least been conservative with his answers concerning items of a "physical nature".

Signed :________________________________________________________ Date:

_____________

Printed name: __________________________________________________