Dating Application

Ok, this is one I stole from Lisa, but it's too funny not to post.

Name

Last

First

Middle

Address:

Address

City

State

Zip

Telephone:

Home

Work

Cell

Date of Birth:

Age

SSN

Weight

Height

Ethnicity: (check)

Black

Hispanic

White

Other

Do you live with any of the following: (circle)

Grandmother

Parents

Mother

Father

Girlfriend

Baby's Mama

Alone

Shelter

Wife

Auntie

Other

Any Children? (circle yes or no)

Yes

No

If yes, how many

How many Baby's Mamas?

If more than one, please name below. Use separate sheet of paper if need more room.

1.

2.

3.

Ever been married (circle )

Yes

No

If yes, how many times?

Are you or have you ever been on the Down Low*? (circle one)

Yes

No

(*If you answer 'Yes' STOP RIGHT HERE )

Do you owe child support*?

Yes

No

Don't Know

*If your ex-wife is getting state benefits (childcare, food stamps, etc), then you owe somebody something. Especially tax payers.   Stop here and go take care of your kids.

Education:

Did you graduate from high school? (circle )

Yes

No

Name of high school (if yes)

Have you received any of the following*? (Circle One)

GED

Diploma

Nothing

*If you did not complete any of the above, please Stop here and return to school.

Any college? (circle one)

Yes

No

Still Enrolled:

Yes

No

Graduated

History:

Have you ever been to jail? (circle one)

Yes

No

If yes, what for? (be very specific)

Have you ever been to prison*? (circle one)

Yes

No

*If you have answered yes to the above question, please Stop here and call your P.O. immediately.

Employed*? (circle)

Yes

No

*If no, please Stop here and go get one.

If yes, where and how long?

Do you have health insurance?

Yes

No

When did you last visit the dentist?

Date

When was the last time you have been to the doctor?

Date

What for?

List any (all) illnesses. Use separate sheet of paper if needed.

Do you have or have you had any of the following*?(please circle all that may apply)

Hepatitis A or  B or C

Herpes

Mononucleosis

HIV/AIDS

The Bird Flu

West Nile Virus

Crabs

Chlamydia

Gonorrhea

SARS

Head Lice

Ringworms

Boils

Sex Change

Shingles

Meningitis

Measles

Mumps

Ebola

Bunions

Virus

Something that you can't spell

*If you have circled any of these, Stop here do NOT turn in your application. See the doctor immediately!

Do you or have you ever used (ingested in any way) any of the following: (circle all that apply)

Crack/Cocaine

Heroin

Paint Markers

Ecstasy

Glue

Bad pills

Snuff

Anything under the kitchen sink

*Please use a separate sheet of paper to compile a list of goals and accomplishments.

By signing below, you agree that all of the information given above is true to the best of your knowledge. For my protection, you may be asked to provide the following information upon request: state ID, birth certificate, recent payroll stub, a recent clean bill of health from a certified physician or practitioner.

Falsifying information may result in termination of this relationship (if applicable), and a severe beat-down by my cousins Woodie-Earl, Billie Ray, Bubba, Pookie, Ray-Ray, Darnell, Lil Krazy or all of the above.

Applicants Name/Signature

Date

Print Name:

Signature: