Date Preference Form

WIP Speed Dating Corp  * Premier Speed Dating For The Selective.

The information submitted on the Date Preference Form enables us to create private events that cater more to the preferences of our clients.

Please print and complete in it's entirety.* Submit by : Mail - Email or Fax*
*Or you can highlight the text below, copy & paste into a word document - answer questions & email as an attachment to date@wipsd.com*

IS THIS FORM A REVISION:    (Yes)       (No) 

Email Address:   _________________________________________________

City:  ________________________________________________

State/Province: _______________________________________

Zip Code: ___________________________

Country: __________________________________

_____________________________________________________________________________________

TELL US A LITTLE ABOUT YOU – circle all that apply.

I’M a:   (Female)  (Male)

I’M:      (Gay)  (Straight)

My Age Group is:             

(21 – 29)  (30 – 39)  (40 – 49)                

(50 – 59)  (60 – 69)  (70 – 79)               

(80 – 89) 

My Ethnicity:                    

(Arab/Middle Eastern)  (Asian/Asian American)  (Black/Afro American)  (Blended/Mixed)                      

(Hawaiian/Pacific Islander)  (Indian/Native American)  (Latin/Hispanic)  (White/Caucasian)                         

Other-please Specify: __________________

Religious/Spiritual Affiliation:                

(Flexible)  (None)  Yes-please specify _____________________________                           

TELL US ABOUT YOUR DATE PREFERENCES – circle as many as desired.

Pref. Gender:   (Female)  (Male)

Pref. Age Group:              

(21 – 29)  (30 – 39)  (40 – 49)                

(50 – 59)  (60 – 69)  (70 – 79)               

(80 – 89)  (No Preference)

Pref. Ethnicity:

(Arab/Middle Eastern)  (Asian/Asian American)  (Black/Afro American)  (Blended/Mixed)                      

(Hawaiian/Pacific Islander)  (Indian/Native American)  (Latin/Hispanic)  (White/Caucasian)                         

Other-please Specify: __________________   (No Preference)

Religious/Spiritual Preference:

(Flexible)  (None)  Yes-please specify _____________________________        

ADDITIONAL DESIRED PREFERENCES-COMMENTS:

 

 

We Are Always Searching For New Locations To Host Events Near You.
Please list 3 or more towns closest to you where you'd like to attend a WIP Event:

1)                                          (2)                                                         (3)                                         

The HMU Community Inc. c/o WIP Speed Dating Corp. P.O. Box 27 Farmingville N.Y. 11738

www.happilymixedup.com * www.wipspeeddating.com * inquiries@thehmuc.com * date@wipsd.com * Toll Free 1-877-947-5888 * Fax-1-888-503-3586