Name * First Name Last Name Gender * Male Female Phone * (###) ### #### Email Address * Location (City & State) * How did you hear about us? * Birth Month * JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC Birth Day * 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 Birth Year * 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 Country of Birth? * If born outside of the U.S., when moved to the U.S? * Ethnicity * Religion/Faith * Political beliefs * Height/Weight * Body type (thin, average, athletic, other) * Would you be willing to relocate Yes No Do you Own or Rent your home * Educational level * College attended (Name and Degree) * Employer Name * Occupation/Position * How long have you worked there * Income * Do you smoke? * Do you drink? How often? * Do you do drugs (recreational or other)? * Do you have any medical issues, illnesses, or STD’s your partner should know about? ? * Do you have children? (If yes, ages) * Do you want children? * Would you date someone with children? * Do you have any pets? * If you were married, or in a long-term relationship tell us why it ended? * Favorite activities/hobbies? * What do you do to stay in shape and be active? * 3 Unique things about you (I won a Grammy, or I’m a great cook)? * * * Tell us about yourself. This part is very important in order for us to understand more about you, and what type of person you’re looking for: ABOUT YOUR PARTNER Ethnicity * Religion * Political Beliefs * Age Range * Body type : (athletic, fit, thin, any) * Gender * What are 3 non-negotiable's when looking for your Partner? * * * Describe your ideal match * I ACKNOWLEDGE AND CERTIFY THAT THE ABOVE INFORMATION IS TRUE AND CORRECT. BY SUBMITTING BELOW, I CERTIFY THAT I'M AN UN-ATTACHED, SINGLE MALE OR FEMALE WILLING AND ABLE TO BE MATCHED UP WITH A POTENTIAL PARTNER, AND ENTER INTO A POSSIBLE RELATIONSHIP IF BOTH PARTIES AGREE. I AGREE TO ABIDE BY ALL THE RULES SET BY MATCH BY JULIA AND JULIA BENDIS, AND AS LISTED IN THE TERMS AND CONDITIONS ON MATCHBYJULIA.COM. I AGREE AND CERTIFY THAT I WILL DO MY DUE DILLIGENCE IN KEEPING ALL PROFILES SENT TO ME BY MATCH BY JULIA AND JULIA BENDIS PRIVATE AND CONFIDENTIAL. I CERTIFY THAT I WILL NOT SHARE PRIVATE PROFILES WITH ANYONE NOR WILL I LOOK UP THOSE INDIVIDUALS ON MY OWN, ON ANY SOCIAL MEDIA OR OTHERWISE. I ACKNOWLEDGE THAT ALL FEES PAID ARE NON-REFUNDABLE. IF I ENTER INTO A DATABASE MEMBERSHIP ONLY, THERE ARE NO GUARANTEES ON THE TIME FRAME OF POTENTIAL MATCHES FOR ME, NOR THE QUANTITY OF MATCHES Thank you for signing up, we'll be in touch with you shortly!Please remember to send 2 recent pictures of yourself to julia@matchbyjulia.comAnd please email if you have any questions at all. PLEASE SEND 2 RECENT PICTURES OF YOURSELF: Photo 1 Photo 2 Submit
