Zip/Postal code *:

Country *:

- No Selection - United States of America

Do you own or rent your home?:

- No Selection - Own Rent

How long?:

Best contact phone number *:

Best contact time *:

- No Selection - Morning Afternoon Evening

Best contact method *:

- No Selection - Home Business Cellular E-mail

Home phone:

Work phone:

Fax:

Cellular:

Your Email *:

How did you hear about GSW?

Friend Flyer Business Card Other Internet Search Engine

Indicate your readiness to begin:

- No Selection - Please contact me as soon as possible I am ready to get started I would like to schedule a complimentary appointment with a consultant

Please explain:

Have you experienced other dating services?

YesNo

Please explain:

Do you travel internationally?

YesNo

If Yes, How frequently?

- No Selection - Occasionally Weekly Monthly Quarterly Annually

To which destinations:

Place of birth *:

Date of birth *:

- No Selection - 01 02 03 04 05 06 07 08 09 10 11 12 Month - No Selection - 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Day - No Selection - 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 Year

Gender *:

- No Selection - Other Famale Male

Height *:

- No Selection - 4 5 6 7 Feet - No Selection - 0 1 2 3 4 5 6 7 8 9 10 11 Inches

Weight

Hair color:

- No Selection - Blonde Black Brown Red White None

Eye color:

- No Selection - Brown Blue Green Hazel

Education:

- No Selection - BS BA MA MS College Some College Junior College High School Vocational Masters Degree MBA MA Ph.D. M.D. D.D.S. JD MBA Bachelor Degree Graduate Degree Associate Degree University Graduate Specialized Degree BBA EdM Multiple Degrees (Describe below)

Describe your education:

Occupation *:

Describe your occupation:

Income *:

- No Selection - 5,000 - 10,000 10,000 - 25,000 25,000 - 50,000 50,000 - 75,000 75,000 - 100,000 100,000 - 150,000 150,000 - 200,000 200,000 - 300,000 300,000 - 400,000 400,000 - 500,000 500,000 - 750,000 750,000 - 1 Million 1 Million +

Assets:

Employed cy:

Are you self-employed?:

YesNo

How much of a financial
investment are you prepared
to make to find your desired
companion?:

- No Selection - Whatever it takes The Minimum

Are you emotionally
prepared for marriage?
(1=lowest, 10=highest):

- No Selection - 1 2 3 4 5 6 7 8 9 10

Are you emotionally prepared for a committed relationship?
(1=lowest, 10=highest):

- No Selection - 1 2 3 4 5 6 7 8 9 10

Please comment on your
emotional preparedness:

Marital status:

- No Selection - Never married Separated Divorced Widowed

If you are separated, divorced,
or widowed, how long?:

- No Selection - 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 Years - No Selection - 0 1 2 3 4 5 6 7 8 9 10 11 Months

If you were married -  how long?:

- No Selection - 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 Years - No Selection - 0 1 2 3 4 5 6 7 8 9 10 11 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

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 believe in marriage
I am shy
I am very outgoing
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?:

What languages
do you speak?:

- No Selection - English Only English and others No English - Others

Please list any other
languages you speak:

Ethnic background:

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
Tennis
Televised Sports
Other

Please describe any other activities:

Do you watch sports?:

YesNo

Please explain:

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:

Do you suffer from any
medical condition?
If yes, please explain.:

About your eating habits:

Meat
Fish
Vegetarian
Natural Foods
Junk Foods
Other

Do you drink alcohol:

YesNo

Frequency:

Seldom
Occasionally
Daily

Are you an alcoholic?:

YesNo

If recovering, how long?:

Do you smoke?:

Yes No

Frequency:

Moderate
Occasionally
Heavily

If yes, how long?:

Have you quit smoking?:

Yes No

About My Match

Age:

to

Comments on age:

Rate their general attractiveness:

- No Selection - 10 (Highest) 9 8 7 6 5 4 3 2 1 (Lowest)

Height:

- No Selection - 4 5 6 7 - No Selection - 0 1 2 3 4 5 6 7 8 9 10 11

Weight:

Hair color

- No Selection - Blonde Black Brown Red White None

Eye color

- No Selection - Brown Blue Green Hazel

What physical qualities
are you attracted to?:

Ethnic preference:

  Gender - No Selection - Other Male Female

About their athletic activities:

Aerobics
Horseback Riding
Boating
Skiing
Cycling
Swimming
Golf
Walking
Jogging
Dancing
Tennis
Televised Sports
Other

Describe any other activities:

Their occupation:

Professional
Entrepreneur
Managerial
Technical
Business Person
Self-employed
Retired
Not Important

Describe any other occupations:

Their education:

High School
Junior College
Vocational
University (4 year)
Masters Degree
PhD
Professional Degree
Not Important
Other

Other levels of education:

Their children:

No Children
Desires Children
Has Children
Not Important

Comment on children:

Their preferred annual income:

- No Selection - 35,000 - 50,000 50,000 - 100,000 100,000 - 300,000 300,000 - 500,000 500,000+ Not Important

Income level comments:

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

1.

2.

3.