INTRODUCTIONS BY ROSEMARY

Confidential Questionnaire

You may either fill out and submit the form to us,
fax the form 714-389-5493 or print it out and mail it to:

Rosemary Packard
537 Newport Center Drive, Suite 184
Newport Beach, CA 92660     714-389-5492
E-mail: rosemaryp@cox.net

First Name

Last Name

Address (including suite #, if applicable)

City:

State:

Zip:

Home Phone: SS #:
Cell Phone: E-mail:  
Birthdate: Height Weight:
Eyecolor: Hair color: Sex: M F
     
Current Occupation:  
Name of Employer:  
Address (including suite #, if applicable)  
 
City: State: Zip:
Bus Phone: Ext:
Employed at this company for: Years   Months
Have been in this field for: Years   Months
     
1) Please indicate where you grew up:
Number of years: Other:  
2) What is your level of education: High School   Jr. College    College
Name of College:
3) Please list any degrees: Masters   Ph.D   Other
4) What is your income level:
$20,000-$40,000 $40,000-$60,000  
$60,000-$80,000 $80,000-$100,000  
Other, Please specify:  
5) Would you date someone who:
Makes an income equal to yours  
Makes an income more than yours  
Income does not matter  
6) What is your marital status:
Single   Separated Divorced months years    Widowed
7) What are your dating goals: Casual    Long term relationship
Long term relationship leading to marriage
8) Do you smoke: Yes No Occasionally
9) Would you date someone who smokes: Yes No Does not matter
10) Do you use drugs socially: Yes No Occasionally
11) Do you drink alcoholic beverages: Yes No Occasionally
12) Do you have children: Yes No   If yes, how many:
Number living with you:   Ages:
13) Do you want children: Yes No Open
14) Would you prefer to date someone who:
Has children Has no children Does not matter
15) Do you have pets: Yes No
If yes, please specify:
16) Will you date someone with pets: Yes No Does not matter
17) Are you allergic to pets: Yes No
If yes, please specify:
18) Would you meet people of different ethnic backgrounds: Yes No
19) What is your ethnic preference:
Caucasian Oriental African American Latino
European Indian Middle Eastern Other
20) What are your political views:
Republican Democrat Conservative
21) What is your religious preference:
22) Do you want your partner to be of the same religion:
Yes No Does not matter
23) Do you attend worship services: Weekly Monthly Yearly Never
24) Do you want your partner to attend worship services:
Weekly Monthly Yearly Never
25) Do you wish to remain celibate in a relationship before marriage:
Yes No Does not matter

26) What personality traits best describe you:
Outgoing Quiet Refined
Shy Romantic Sensual
Independent Confident Spiritual
Ambitious Sophisticated Controlling
Open Communication Compassionate Moody
People Orientated Perfectionist Passionate
Trusting Athletic Intense
Free Spirited Professional Carefree
Supportive Adventuresome Sensitive
Calm Conservative Religious
Sense of Humor Creative High Morals
Positive Health Conscious Cultured
Spontaneous Organized Emotional
Optimistic Extrovert Punctual
Introvert Flexible Friendly
Structural Happy Compulsive
Tidy High Energy Risk Taker
Argumentative Educated
List Other traits:
27) What are your recreational activities:
Travel Golf Dancing
Jogging Boating/Sailing Aerobics
Dining Out Body Building Reading
Motorcycling Watching Television Swimming
Theater Snow Skiing Movies
Water Skiing Concerts Roller Blading
Musicals Hiking Opera
Tennis Volunteer Work Snorkeling
Politics Bicycling Camping
Gardening Cooking Museums
Jazz Horseback Riding
List other activities:
28) Do you have any health problems:
Yes No If Yes, explain:
29) Do you have any special dietary preferences or eating habits:
Yes No If Yes, explain:
30) Do you exercise:
Yes No If Yes, how often:
31) Do you travel:
Yes No If Yes, how often:
32) Where do you enjoy travelling:
Local U.S. Worldwide
33) What is your favorite travel location:
34) List personality traits most important to you in a mate:
35) List personality traits NOT compatible with you:
36) Describe your ideal mate (Approximate ranges)
Age: Height: Weight:
Hair color: Eye Color: Children:
Personality:
Preferred Geographic Location: Orange Co. Only
Long Beach Los Angeles San Diego
Southern Ca Other:
37) Have you been involved in a dating service before:
Yes No If Yes, explain:
38) Is there anything you would like done differently:
39) How did you hear about "Introductions by Rosemary":
Friend Advertisement Yellow Pages
OC Metro Christian Times  
Other - Please specify:  
     
Signature: Date:

Press "Submit Button" to send
form to Rosemary.
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