Please Be As Thorough As Possible.
This Will Assist Us In Getting You Quicker Results!
You do not have to answer any questions you feel are not appropriate!

Please Fill Out Both Part 1 & 2 Of This Form

Please hold down the control key when making multiple selections in the multiple choice boxes.

Part 1 : Member Information

 

Name
Address
City
Province/State
Country
Postal/Zip Code
Phone
Fax
E-mail

 

Male Female Age
Birth date DD MM YY
Nationality
Height
Weight
Hair Color
Eye Color
Occupation

Education

Marital Status

Do you have Children? Yes No
How Many
Ages
Do you want to have Children Yes No
Do you Smoke Yes No
Do you Drink Yes No Socially
What is your First Language

What languages do you speak?

Other

What is your Religious Belief?

I attend Synagogue:

Political Feelings

Hobbies

Other

Athletic Activities

Other

Musical Taste

Other

Which rules you more?

The head The heart

Do you prefer?

A large group of friends A small group of friends

Viewing Interests

Other

What general activities do you enjoy the most?

 

Part 2: Information About the Companion You Seek

 

Smoker Nonsmoker
Parent Non-Parent

Their Religious Belief?

Attend Synagogue:

Weight

Height

Minimum Maximum

Age

Minimum Maximum

Education

What are the most important characteristics you are looking for in a companion?

Which of the following best describes your view of a future spouse?

Is it acceptable for us to introduce you a partner with children?

Yes No

How important do you believe a healthy sexual relationship is in a marriage?

Comment on your feelings toward marriage?

What are the three most important things about yourself?

Your Final Comments

Please indicate the Cities where you would like to find your "Special Someone"

 

Photograph

Enclosing your photograph is helpful to our counsellors

OPTIONAL INFORMATION

Is there anything about our questionnaires you feel we could improve upon?

Here are some friends that I feel would benefit from your services!

Friend 1

Name
Address
City
Province/State
Country
Postal/Zip Code
Phone
Fax
E-mail

Friend 2

Name
Address
City
Province/State
Country
Postal/Zip Code
Phone
Fax
E-mail

 

Thank You!

Please select your

Method of Payment

The Three Month membership is $595.00

The Six Month Membership is $895.00

The One Year Membership is $1,495.

 All funds are in United States Dollars

Choose Your Preferred Method of Payment Below (SPECIAL BONUS: as the transaction costs of processing them are smaller, you may deduct an ADDITIONAL 10% DISCOUNT from the applicable membership fee when paying by: Personal Check; Money Order; or Bank Wire Transfer.  There is no additional discount when paying by Credit Card or Western Union Transfer.  Please note that we can not accept payment by Cash)

Name on card
Credit Card #
Expiry Date
Amount $
*CVV    

*Visa, Mastercard, Discover:  3  digit  number appears on the back of the card on the after the last four digits of the card number;   American Express: 4 digit non-embossed number printed above the card number on the face of the card.

 

If you prefer, you may send us your application by mail.  Your membership will be activated upon receipt.  Please make payment out to "Intro World International" and mail to our international office at:

J.I. c/o Intro World Int'l
377 East 35th Ave.
Vancouver, B.C.   V5W 1A7
Canada

 

 

 

E-mail: contact@jewishintroductions.com