Fire Escape's Dating Application and Compatibility Questionaire

WWW: http://www.fehq.org, E-MAIL: fire.escape@fehq.org

For someone serious about finding that permanent partner this
application may help avoid a huge waste of time and emotional resources
on unsuitable people. Please be honest and concise with your answers.

I. General Background Information (Please Print Legibly, if possible)

A.  Personal/Family

    1. Name of Applicant (Last, MI, First):
    2. Current Address:
    3. Home Owner or Renter?:
    4. Location of Previous Residences and Times of Habitation
:
    5. Age of Applicant:
    6. Birthdate (mm/dd/yy):
    7. Place of Birth:
    8. Gender:
    9. Sexual Orientation:
    10. Race/Ethnic Group/Nationality:
    11. Marital Status:
    12. Previous Marriages? Years of Marriage/Divorce Date(s):

    13. Children from Previous Marriage?, Names/Ages:       

    14. Parents Full Names:
    15. Parents Occupations:  
    16. Siblings?, Names and Ages:

    18. License Plate Number:
    19. Car Make and Model:
    20. Car Insurance Policy with:
    21. Home Phone Number:
    22. Work Phone Number:
    23. Cellular Number:
    24. Beeper Number:
    25. E-Mail Address:
    26. WWW Home Page URL:  
    27. Pets? (Species/Names):
    28. Personal Achievements or Awards:

    29. Community Sevice Projects (Past +/or Present):

    30. Hobbies/Interests:
    

B.  Educational History and Information

    1. High School(s) Attended and Year of Graduation:
    2. Grade Point Average in High School and College:
    3. Academic Area of Interest, Ability and Difficulty (respectively):

    4. Extra-Cirricular Activities or Clubs:

    5. Favorite Teachers/Professors and Reason Why:

    6. Ever Suspended or Expelled? Explain:

    7. Classes Failed? Explain:
    
    8. Member of NHS (National Honor Society)?
    9. Athletic or Academic Awards/Acheivements:

    10. Colleges/Tradeschools Attended and Year(s) of Graduation: 
    11. Currently enrolled in educational program? If So, Where:  
    12. If a Student, What year or level:
    13. Degree Program or Major:
    14. Accumulated Credit Hours to Date:
    15. Present number of credit hours presently enrolled in:
    16. Present Classes (Names, Days and Hours):

    17. Dorm or Commuter?
    18. Recieving Financial Aid or Loan? Details:
    19. Academic Scholarships? Details:


C.  Financial History and Information

    1. Drivers License Number/SSN:
    2. Bank/Checking Account Information:

    3. Major Credit Cards, Limits and Current Balances:


    5. Regular Donation to Charities? If so, Which ones?
    6. Monthly Utilities Bill (average) :
    7. Student or Consolidation Loans owed? Details:
      
    8. Currently Employed? By Whom? How Many Months/Years with Current Employer?

    9. Past Employers (Mo/Yrs employed):

    10. Current Financial Obligations/Debts (House, Car payments etc..) Details:

    11. If Employed, annual net income (after taxes):

    12. If Employed, average hours worked per week:
    13. If Employed, paid for overtime?
    14. If Employed, do you like your present job? Explain:

    15. Your 5 Year Career/Financial Goals are:
    16. Your 10 Year Career/Financial Goals are:
    17. Your 20 Year Career/Financial Goals are:
    18. How would you describe your Work Ethic?

    19. What your opinions and feelings about Public Welfare?

    20. Do you have and IRA or deposit regularly to a Savings Account?


D. Health History and Information

    1. Name and number of current Primary Care Physician:
    2. Current Health Insurance?:
    3. Have you ever been hospitalized? Details:

    4. Have you ever had any serious illnesses or diseases? Details:

    5. Are you immuinzations current?
    6. Do you have any genetic disorders? Details:
    7. Have you ever had a sexually transmitted disease? Details:

    8. Are you HIV Negative? Date and Laboratory of Last HIV Test:
    9. Have you ever been institutionalized or treated for any mental disorders?
        Details:
  10. Do you have any heart conditions?
  11. Are you presently afflicted by any health disorders or conditions? Details:

  12. Are you taking any prescription medications currently? Details:

  13. Have you ever done any recreational (illegal) drugs? Details:

  14. Do you smoke cigarettes or chew tobacco?
  15. Do you drink alcohol? If yes, how freqently?

E. Physique

   1. Height:
   2. Weight:
   3. Eye Color:
   4. Hair Color (natural):
   5. Shoe Size:
   6. Ring Size:
   7. Dress or Shirt Size:
   8. Pants Size:
   9. Collar Size:
 10. Sleeve Length:
 11. Inseam Length:
 12. Vision:
 13. Corrective eyewear?


II. Personal Preferences and Opinions

A. Likes (Fill in the Blank)

    1. Favorite Color (why?):
    2. Favorite Song (why?):
    3. Favorite Car Brand:
    4. Favorite Vocalist:
    5. Favorite Actor and Actoress:
    6. Favorite Fast Food Place:
    7. Favorite Soda:
    8. Favorite Kind of Food (nationality):
    9. Favorite Movie (theater):
  10. Favorite Animal (species):
  11. Favorite Restaurant:
  12. Favorite Activity for Dating:
  13. Favorite Gemstone:
  14. Favorite Flower:
  15. Favorite Time of the "Day" (why?):
  16. Favorite Season (why?):
  17. Favorite Day of the Week (why?):
  18. Favorite Candy:
  19. Favorite Subject of Conversation:
  20. Favorite Joke (tell in person):
  21. Favorite Sport (watching, participation):
  22. Favorite Physical Feature:
  23. Favorite Flavor of Icecream:
  24. Favorite Kind of Cake:
  25. Favorite Kind of Pie:
  26. Favorite Room in the House (why?):
  27. Favorite Quote:
  38. Favorite Game:
  29. Favorite Holiday (why?):
  30. Name something you wished you had more time for:

B. Dislikes (Fill in the Blank)

    1. Most disliked color:
    2. Most disliked song:
    3. Most disliked car brand:
    4. Most disliked food (specific):
    5. Worst time of the "day" (why?):
    6. Worst day of the week (why?):
    7. Worst season of the year (why?):
    8. What do you hate to do most (why?):
    9. What do you most hate to talk about (why?):
  10. Most disliked Sport:
  11. Who do you avoid the most (why?):
  12. Worst Joke (tell in person):
  13.Your Worst Personal Habit:
  14. Your Worst Personality Trait:
  15. Which physical feature do you dislike the most on yourself (why?)
 
  16. Most disliked household chore:
  17. Most disliked location/place:
  18. Most disliked "cliche":
  19. Most disliked personal responsibility:
  20. Worst thing anyone has ever said to you:

  21. Worst personal life crisis to date (details):

  22. What one things gets on your nerves more than anything else?

  23. If you could change one thing about yourself, what would it be and why?


C. Self-Evaluation Statements

     Rate the following statements on a scale of 0 (zero) to 5 (five). Where
     0 - Never true, 1- Rarely True, 2 - Sometimes True, 3 - as much true as false,
     4 - Mostly True, and 5 - Always True.

    1. I Love to get up with the birds:
    2. I sleep like a rock:
    3. Talking bored me:
    4. I hate to cook:
    5. Housecleaning is women's work:
    6. I'd rather be happy with work and underpaid than overpaid and unhappy:
    7. Rain is depressing:
    8. Summer is just too hot:
    9. Girls should play hard to get:
  10. Real men don't wear jewelry:
  11. I love to read books:
  12. I'm a TV couch potato:
  13. I hate drawing attention to myself:
  14. I like to eat alone:
  15. I love crowds:
  16. I'd rather splurg on others than treat myself:
  17. I'm impulsive and rash:
  18. I hate surprizes:
  19. I would rather save for a rainy day than spend it while I have it:
  20. Revenge is a dish best served cold:
  21. If at first you don't succeed, give up:
  22. The best things in life are free:
  23. The grass is always greener on the other side of the fence:
  24. I always get my way:
  25. I like my solitude:
  26. I frequently argue with myself:
  27. Children are a blessing:
  28. I'm easy to please:
  29. I'm my own worst enemy:
  30. I always tell the truth:  
  31. I have a lot to contribute to a relationship:
  32. I am usually in a good mood:
  33. I am pleased with my appearance:
  34. I'm an intelligent person:
  35. I am ashamed of myself:
  36. I am content with the number of my friendships:
  37. I am energetic:
  38. The glass is always half full, not half empty:
  39. I can laugh at most of my mistakes:
  40. I'm an interesting person:
  41. I'm comfortable with my sexuality:
  42. Other people care about me:
  43. There is nobody quite like me:
  44. I'm still under construction:
  45. If I could do everything all over again, there isn't much that I'd change:
  46. I'm a considerate person:
  47. I have many regrets about my life:
  48. People value my opinions:
  49. I am hesitant to express my feelings:
  50. I know for sure I will go to heaven when I die:
  51. I lose my temper frequently:
  52. Nothing is too good for me:
  53. There aren't many people I'd trade places with:
  54. I like to plan things out:
  55. Caution is the better part of valor:

D. Politics

    1. Do you belong to any specific political party? If so, which: 
    2. Are you a registered voter? If so , do you vote regularly?

    Briefly give you opinion ,if any, in the following topics:

    3. Abortion:
 
    4. Prayer in Public Schools:

    5. Homesexual Rights:
 
    6. Middle-Eastern Policies:
 
    7. Foreign jobs and trade:

    8. The National Debt and Deficit:

   9. War on Drugs:
 
  10. Unemployment and Welfare:

  11. Military Spending:

  12. Enviromental Concerns:

  13. Space Exploration Program and Funding:

 14. Social Security:

 15. HMO reform and public health care:

 16. Captial Punishment and Prison Reform:


E. Moral and Spiritual Views

   1. Religion (if any):
   2. Denomination or Sect (if any):
   3. Is there a God or Higher Power?
   4. If there is a God, Is that God personal or impersonal?
   5. Are there absolutes; does sin exist or is it all relative?
   6. What is our relationship to God if He/She/It exists?
   7. Do you believe there is life after death?
   8. Do you believe in reincarnation?
   9. Did Jesus exist, if so - who was he?
 10. If you have kids, what will you teach them about God, if anything?

 11. Friendship is:
 12. Leadership is:
 13. Forgiveness is: 
 14. Courage is:
 15. Love is:
 16. Compassion is:
 17. Honest is:
 18. Fear is:
 19. The Purpose of Life is:
 20. Happiness is:

F. Miscellanous Opinions

   1. If you were granted one wish, what would you wish for?

   2. If you had all the money you could ever want, what would you do with it?

   3. What would you do if you were the only person left on earth?

   4. If you could spend one day of your life as someone else, who would you
       pick and why?

   5. If you were to write a book about me, would it be fiction or non-fiction?
       Suggest a title.

   6. How would you go about eliminating world hunger and poverty?

   7. What's the best thing anyone has ever said to you?

   8. List the things that would be on your plate if you were eating your "last meal".

   9. In life there are those who serve and there are those who are served. Which
       one best decribes you.

  10. Is there anything that you would be willing to die for?