Your full name:
Your email address:
Your phone number (with country, city, area codes):
Address:    
City/Town:  State/Prov.:   Post./Zip Code:
Country: 

Date of Birth:  Month Day Year

Height (cm)     Weight (lbs)     Complexion 

Religion

Home Owner ?          Yes   No       Home Renter ?             Yes   No
Apt/Condo Owner ?   Yes   No       Apt/Condo Renter ?    Yes   No
Others, Please Specify

Do you hold a current driving license ?   Yes   No  and own a car ? Yes   No

Have you had a bank savings/cheque account for the last six months?   Yes   No

Are you in full employment ? Yes   No   Type of employment
If not employed do you have sufficient funds to support a wife and proof of such ? Yes   No

Status Single Divorced Widowed
If divorced, do you have original or certified copy of Decree Absolute ? Yes   No
If widowed, do you have original or certified copy of death certificate ?  Yes   No

Do you have children ?  If so please state number, sex and age
Do any of your children live with you ? If yes please state number

Are you free to travel to Thailand within the next 6 months ?   Yes   No
Have you been to Thailand previously ?  Yes   No

How did you find us?  Newspaper Ad Word of Mouth Internet Search
If newspaper ad, which newspaper
If internet search, which search engine

In brief, please describe yourself and your interests, and any other relevant information

"PLEASE CAREFULLY AND ACCURATELY RE-ENTER YOUR EMAIL ADDRESS HERE.  AS
IF AN ERROR OCCURS WE CANNOT EMAIL YOU BACK!!"