Personal
First Name*
Last Name*
Gender
Male
Female
D.O.B - Date of Birth requested for verification purposes only pursuant to 18 U.S.C. §§ 2256 et seq.
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
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
January
February
March
April
May
June
July
August
September
October
November
December
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
Contact Information
City*
State (Province)
Alabama
Alaska
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California
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Connecticut
Delaware
District Of Columbia
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Ohio
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Pennsylvania
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Tennessee
Texas
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Vermont
Virginia
Washington
West Virginia
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British Columbia
Alberta
Saskatchewan
Manitoba
Ontario
Quebec
New Brunswick
Nova Scotia
Prince Edward island
Newfoundland & Labrador
Northwest Territories
Yukon Territories
Nunavut
Mobile*
Home Phone
Email*
Education / Employment Information
Occupation
Show Questions
Tell us about your family::
Describe your relationship with your Son/Daughter::
Describe your relationship with the boyfriend/girlfriend of your son/daughter::
Why do you think your son/daughter is dating this person?:
Describe the ideal type of girl /guy you would like your son/daughter to date::
How were you referred to the show?:
