First Name*

Last Name*

Gender*

Phone Number*

Email Address*

Residence (City)*

Residence (State)*

How did you hear about us?*

Birthday*

Country of Birth*

If born outside of the U.S., when did you move to the U.S?

Ethnicity*

Religion/Faith*

Political beliefs*

Height*

Weight*

Body type*

Thin

Average

Athletic

Other

Would you be willing to relocate? *

Do you own or rent your home/apartment? *

Education level*

College attended (Name and Degree) if applicable?*

Employer Name*

Occupation/Position*

How long have you worked there?*

Income/yr*

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 (what kind)?
*

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)

#1*

#2*

#3*

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/Faith*

Political beliefs*

Age Range*

Body type*

Thin

Average

Athletic

Other

Gender*

What are 3 non-negotiable's when looking for your Partner?

#1*

#2*

#3*

Describe your ideal match*

Please attach 4 recent pictures of yourself (Resolution should be less than 1MB each and jpeg format)

Photo 1*

Photo 2*

Photo 3*

Photo 4*

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