Los Angeles Prime Timers Questionaire Form

Los Angeles Prime Timers

Profile Questionnaire

Please complete the form first then print
it and send it in with your check.

NOTE: USE DARK INK. PRINT CLEARLY.

FOR OFFICE USE ONLY

Nbr: ______________ Exp: _______________

First Name Only:

Best Time to Call:

Telephone:

Cell Phone:

Email:

I live in or near: (e.g. Glendale, North Hollywood, Zipcode, etc.)

I am in a long-term relationship Yes No

I wish to meet someone special Yes No

Check the codes to indicate your interests

	Swimming
	Telephone Talk
	Theatre
	Travel
	Volunteering (Community)
	Volunteering (PTWW)
	Walking
	Window Shopping
	OTHER (Do not type past box limit)

I would like to meet someone who is:

(Do not type beyond limits of box)

My favorite intimate activities are:

(Do not type beyond limits of box)

http://www.laprimetimers.org