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This application must be answered in full prior to permission being granted to date my daughter. Remember all answers will be checked for valid responses. Please consult your life insurance agent to verify that all beneficiaries are current and additional coverage is applied for if needed prior to turning this application in.
Name:_________________ Date of Birth:___________________
Home Address:_______________________________ City:__________
State:_________ Zip:___________
Social Security #:________________________________
Drivers License #:________________________________
Height:_________ Weight:__________
I.Q.:________ G.P.A.:___________
Boy Scout Rank:_____________
1. Do you have one male and one female parent? (Yes / No)
If no, explain: ____________________________________________
2. Do you own a van? (Yes / No)
a truck with over-sized tires? (Yes / No)
a waterbed? (Yes / No)
(Note: if you answer yes to any of #2, put down your pencil,
discontinue application, and leave premises)
3. In 50 words or less, what does LATE mean to you?_________
____________________________________________________________ ____________________________________________________________
____________________________________________________________
4. In 50 words or less, what does DON'T TOUCH MY DAUGHTER
mean to you? _______________________________________________
____________________________________________________________
____________________________________________________________
5. In 50 words or less, what does ABSTINENCE mean to you?_
____________________________________________________________
____________________________________________________________
____________________________________________________________
6. Do you have an ear ring, nose ring, belly-button ring or
tattoo? (Yes / No)
(Note: if you answer YES to any of #6, put down your pencil,
discontinue application, and leave premises).
7. Church : (Yes / No)
How often do you attend?_________
8. When would be the best time to interview your father? mother?
priest/pastor?
____________________________________________________________
9. Answer by filling in the blank. Please answer freely - all
answers are confidential.
(That means I won't tell anyone - ever - I promise.)
A. If I were shot, the last place on my body I would want to
be wounded is in the . . .
___________________________________________________________
B. If I were beaten, the last bone in my body I would want broken
is my . . .
___________________________________________________________
C. A woman's place is in the _______________________
D. The one thing I hope this application does not
ask me about is . . .
__________ ___________________________________________________________
E. When I meet a girl, the first thing I notice
is her . . .
____________________________________________________________
(Note: If answer E begins with "T" or "A", put down your
pencil, discontinue application, and leave premises - keeping
your head low and running in serpentine fashion is advised.)
10. What do you want to be IF you grow up?
_____________________________________________________________
I SWEAR THAT ALL INFORMATION SUPPLIED ABOVE IS TRUE AND
CORRECT TO THE BEST OF MY KNOWLEDGE; UNDER PENALTY OF DEATH,
DISMEMBERMENT, NATIVE AMERICAN TORTURE, CRUCIFIXION,
ELECTROCUTION, CHINESE WATER TORTURE, AND RED-HOT POKERS.