The ALternative Questionnaire for Dating

The ALTERNATIVE

Social Agency

Confidential Questionnaire.

Please note: Although it is most unlikely that you will experience any problems responding to this form, certain non-standard browsers will not respond properly. If you experience any difficulties, (or if you are not using a forms-capable browser) you may email your response to this form to: E-mail Louise.

All information provided is sent directly to The ALTERNATIVE and is held in strict confidence. No information provided will be used for mailing lists or given to other agencies.

Note: Required fields are indicated with an *.

*First Name:

*Last Name:

*Age:

*Address:

*City:

*Province/State or Country:

*Postal or Zip Code:

Home Telephone:

Business Telephone:

*E-mail Address:

Occupation:

Height:

Weight:

Education:

Income:

Gender:

Your Marital Status (Multiple items may be chosen)

Never Married
Married
Separated
Divorced
Widowed

Tell Us About Yourself

Tell Us About the Person You Are Seeking

What are the three most important considerations about the person you wish to meet?

1st: 2nd:

3rd:

Select Your Membership Type:

3 Months for $300 (Basic)
6 Months for $400 (Silver)
One Year for $600 (Gold)
Two Years for $1,000 (Platinum)
VIP $5000 for personal executive search

TO JOIN ONLINE, PLEASE FILL OUT THE FOLLOWING CREDIT CARD INFORMATION FORM. (If you decide to join in person, Cash, Cheque & Debit Card payments will also gladly be accepted)

Credit Card Payment Options

Credit Card
Card Number
Cardholder Name
Expiry (month/year)	/

We accept all methods of payment.

Special Comments and Requests:

How Did You Find Out About Us?

Internet Search
Personal Referral
Print Advertisement
Other

Preferred Method For The Alternative To Contact You?

Home Phone
Business Phone
Cell Phone Cell #:
E-Mail

Preferred Time For The Alternative To Contact You?

Morning
Afternoon
Evening

Louise Watson
THE ALTERNATIVE
Corporate Office
Mississauga, Ontario
Telephone: (905) 569-9795
louise@altcanada.com