Application to Date me

Note: This application will be incomplete and rejected unless accompanied by a complete financial statement, criminal history, driving record, job history, and current health record/medical report from your physician.

Name:__________________________________________

Date of Birth: ____________________________________

Height: _____________ Weight: _____________________

IQ: ________ Social Security Number: ________________

Drivers License Number: ___________________________

Home Address: ___________________________________

Do you own a van? _________

A truck with oversized tires? ________

A waterbed? ________

A pick up with a mattress in the back? ______

Do you have an eyebrow, nose ring, or belly button ring? _______

A tattoo on your neck? ________

Do you have a mullet? ________

NOTE: If you answered yes to any of the last 7 questions, discontinue and leave premises.

How many times have you been married? _____________________

How many times have you been divorced? _______________________

Have you ever cheated on a girlfriend or wife? ______________________

When going on a date, who should pay? _________________________________

Have you ever been accused or convicted of stalking? ______________________

If I tell you to drop dead today will you continue to contact me? ______________

Do you know how to cook? __________________

What is your relationship like with your mother? _____________________
(you shouldn’t need ANY more space than that for this answer)

Do you own a dog? _______________

What is your definition of an alcoholic? ____________________________

Do you like kids?___________________

Do you have kids? ____________________

Do you pay child support? _______ How much? ___________

Have you ever been late on your child support payments? ________

How much baggage do you carry?___________

Are you able to fix my car?____________

Do you own a home?____________Have you ever been late on your mortgage?_________

What kind of vehicle do you drive? ___________

Do you have a car payment? __________ How much is it? ____________

Do you know the different between the dinner fork and the salad fork? __________

In 50 words or less what does “LATE” mean to you? ______________________________________________

In 50 words or less, what does “STALKING” mean to you?__________________________________________________

In 50 words or less what does “GOING ON A DATE” mean to you?


Signature:____________________________________________

Your signature indicates that all answers are TRUE. If you are found falsifying answers and/or documents you will be sent hunting with Cheney.

Thank you for your interest. Please allow four to six years for processing. You will be contacted in writing if you are approved. Please DO NOT call or write during the processing time.