*Name:
(First Name Last Name)
*E-mail:
*Main phone:
Secondary phone:
Best Day to reach you:
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Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Best time on this day to reach you:
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morning
lunchtime
afternoon
afterhours
Street Address:
City:
State:
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip:
About You:
Marital Status
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Never been married
Married
Separated
Divorced
Widow(er)
Birthday:
Month-->
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day: Year:
Number of Children
Children Housing status
At home
Shared
Grown - out of the house
-
Occupation
Income
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<$70K
<$100K
<$300K
<$500K
>$500K
Number of hours per week spent working
Educational Background
Religion
Religion of my match:
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Will consider outside of my religion
Only of my religion/beliefs
Hair Color
Eye Color
Ethnicity
Height
ft in
Weight
lbs
Body Type
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Slim
Average
Athletic
Couple extra pounds
Overweight
Drinking Preference
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Not at all
Socially
Habit
Smoking Preference
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Not at all
Socially
Habit
Work Out
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Not at all
Sometimes
Regularly
Religiously
Please tell us about yourself
(expand on: education, travel, marital status, kids, hobbies, music)
Please describe your perfect match
(ex: age range, kids, hobbies, passions)
Comments/questions:
*How did you find us?
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Google Search
Postcard/Mail Ad
Referral from a Friend
Met Gayle at an event
Magazine/Newspaper Ad
TV
Other (please specify)
other:
Would you consider becoming a client?
Not at this time
Yes, please contact me about both options
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(All photos are kept strictly confidential and will only be used by Chicago Matchmakers to assist during your initial consultation /conversation.)