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Registration Form:

Register for this event date: March 14th, 2015 La Placita Restaurant on Revolution Ave
First Name
Last Name
Age
Do you want children? Yes   No
Do you have children? If so, how many do you have?
Do you speak English? Yes   No
Level of Education:
Religion:
Do you smoke? Yes   No
Do you drink? Yes   No
Tell us about yourself:
What kind of woman are you looking for?
What is your age preference in a woman?
Race Preference?
Street:
Street 2 (optional):
City:
State:
Country:
E-mail Address:
Phone (Land Line):
Cell Phone:
Do you have a current passport/visa to enter the USA? Yes   No

Would you like to make your picture and profile public to single men?
(Single men in the USA/Mexico will be able to view your profile with picture and request a date with you.) If you answer 'No' then your profile will only be seen by 'registered' single men in our agency and NOT to the general public browing our site. Your phone number, e-mail address and residential address are NEVER revealed to the public.
Yes   No

Please READ and Sign your Name so that you agree with our Privacy Policy:
We will never sell any of your personal information. We will make your information available to single members of this agency on our website ONLY for dating purposes. Your full-name, phone number, residential address and email will never be shown or sold to other singles. Our web application will hide your e-mail address so it is never revealed.
Important: You also must agree to our 'terms of use' and 'privacy policy'.
Signature: