Dating Application
Name _________________
Last First ______________
Middle ________________
Address __________________________________________________
City _________________________ State _____ Zip ___________
Home .. _________________ Cell.. __________________
Do you live with any of the following: (circle)
Grandmother Parents Mother Father Girlfriend
Baby Mama Baby Daddy Alone Shelter Wife Auntie Other _________________
Weight _______ Height ________ Ethnicity: Black Hispanic White Other_________________
Date of Birth ______________ Age ____ SS.. _____-___-_________
Any Children (circle yes or no) yes no If
yes, how many _______
How many Baby Mamas (Daddies)? _________
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? _______
Please answer the following:
MALES: Are you or have you ever been on the Down Low? (circle one) Yes No
*If yes, please stop here, put your pen down, and get the hell out of my face.
FEMALES: Are you, or have you ever been, sexually involved with another woman? (circle one) Yes No
*If yes, don’t worry, I’m sure we can find a way to work something out. Please continue with application.
Do you owe child support? (Circle one) Yes No Don't Know
*If your ex 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.
*Please use a separate sheet of paper to compile a list of goals and
accomplishments.
Did you graduate from high school? (circle one) 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 Graduated
Have you ever been to jail? (circle one) Yes No
If yes, what for? (be VERY detailed)
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
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 resume this application after you get a job.
If yes, where and how long?
____________________________________
_______________________________________________________________
_______________________________________________________________
Do you have health insurance? Yes No
When did you last visit the dentist? ______________________________
When was the last time you have been to the doctor?
__________________
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)
Hep A; B or C, Herpes, Mononucleosis,
HIV/AIDS, The Bird Flu, West Nile Virus, Crabs,
Chlamydia, Gonorrhea, SARS, Head Lice, Ringworms,
Boils, Sex Change, Shingles,
Something that you can't spell, Meningitis, Measles,
Mumps, Ebola Virus, Bunions
*If you have circled any of these, do NOT turn in your application. See
the doctor immediately and leave me the hell alone.
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
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), severe stalking, trashing of your reputation, busted windshields, slashed tires, and a severe ass whooping by my project cousins Pookie, Ray-Ray, Darnell, Lil Krazy or all of the above.
Applicant 's Signature
______________________________________________________________
Print Name
_______________________________________________________________
Date ________________________________________
This is funny as hell! I need to start using this
Good One! I'm thinking folks should really consider using something like this! No joke!
VP#27 IT'S LOOK LIKE YOU COVERED ALL NEEDS OF ANY ONE BASIC IMFO FOR THEIR MATE.....BUT EASIER, NO/NEVER
THERE'S NODOUT ONCE THIS AP IS DONE, EITHER THE TRUTH
OR LIES WILL SHOW WHO'S WHO.....I DOUT IF ANYONE WILL
GET A DATE AFTER THEY FILL THIS THING OUT....GOOD WAY
TO OPEN UP FOR SOME REAL S***,BUT THIS WILL GET WHAT
DIDN'T WANT.......HUH?
