^The Christian Singles Info-exchange

PROFILE ANSWER SHEET

Print this page, and refer to the Paper Version - Questions and Answer Sheet for instructions

Name: __________________________________________________
Addr: __________________________________________________
City: ______________________ ST: __________ Zip: ____________
Daytime Phone or Voice Recorder: (____) ______________________

Contact Information (Released to other members.)

Name:______________________________________________
Addr:______________________________________________
City:______________________ ST:_____ Zip: _________
Phone: (_____)_________________ Best time:_______________

  [_] FOR LADIES ONLY: (optional) I don't feel comfortable initiating the first communication with
     a gentleman, please contact me as directed above.
  [_](optional)Please contact me by mail through CSI using my Member number. I do not want to release
     any (more) contact information here.

101. ______________ (okay to leave blank)
102. [_]M,   [_]F
103. [_]1,   [_]2,   [_]3,   [_]4 and [_]D,   [_]N,   [_]W
104. _______ time(s).
105. Birth date: MO._______, DAY _____, YR ______.
106. Number: ___ Letter: ___
107. [_]1,   [_]2,   [_]3,   [_]4,   [_]5,   [_]6,   ____________
108. ________ INCHES,  and  [_]1,   [_] 2,   [_]3,   [_]4
109. ________ years
110. _____________________________________________________.
111. _____________________________________________________.
112. _____________________________________________________.
113. Zip: ____________ City: ___________________.
      [_]1,   [_]2,   [_]3,   [_]4,   [_]5,   [_]6 __________________________.
114. _______ children, ages: ____, ____, ____, ____, ____, ____, ____, ____.
115. I LIVE WITH _____ child(ren) or other dependent(s).
      ______________________________ _________.
      ______________________________ _________.
      ______________________________ _________.
      ______________________________ _________.
      ______________________________ _________.
201. Mother: ______________________________, Father: ______________________________.
202. ___________________, and [_]C,   [_]T,   [_]F,   [_]O
203. Sisters: ______,   Brothers: ______ and [_]1,   [_]2,   [_]3,   [_]4
204. ______ and [_]a,   [_]b
205. ______ years and [_]A,   [_]H,   [_]O
Branch: ________________________________________________________ .
206. States: _______, Countries: _______
207. [_]C,   [_]L,   [_]M,   [_]N,   [_]O ________________________.
208. [_]1,   [_]2,   [_]3 _________________________________.
209. [_]1,   [_]2,   [_]3,   [_]4,   [_]5
210. [_]1,   [_]2,   [_]3,   [_]4,   [_]5
211. DUI/DWI: _______ (_________________________________.)
212. Felonies:  _______ (_________________________________.)

401. [_]P,   [_]M,   [_]R,   [_]N,   [_]O ______________________________________.
402. [_]1,   [_]2,   [_]3,   [_]4,   [_]5
403. [_]1,   [_]2,   [_]3,   [_]4,   [_]5,   [_]6,   [_]7 ___________________________________.
     [_]P,   [_]N,   [_]U
404. [_]C,   [_]L,   [_]N
405. _______ hours
406. [_]M,   [_]N,   [_]B
407. [_]I,   [_]O,   [_]B
408. [_]Classical,   [_]Country-Western,   [_]Easy Listening,   [_]Gospel,     [_]Jazz,
     [_]Rock & Roll,   [_]Top 40,   [_]Other: _________________
409. [_]A,   [_]B,   [_]C,   [_]D,   [_]E,   [_]F,   [_]G,   [_]H,   [_]I,   [_]J,   [_]K,   [_]L,   [_]M,
     [_]N,   [_]O,   [_]P,   [_]Q,   [_]R,   [_]S,   [_]T,   [_]U,   [_]V,   [_]W,   [_]X,   [_]Y,
     [_]Z,   [_]1,   [_]2,   [_]3,   [_]4,   [_]5,   [_]6,   [_]7,   [_]8,   [_]9,   _____________________________ .
501.
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________.
502.
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________.
503.
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________.

Photograph Information and Notes (For instructions refer to full version. Please put your name on the back of each photo.)

601. Year: ____________________.
602. ___________________________________.

Membership Agreement (Membership cannot be completed unless this Agreement is signed.)

By my signature below, I hereby certify that I meet the "Eligibility Requirements" published herein, and that all of the information given on my Profile Questionnaire is correct to the best of my knowledge.  I hereby authorize The Christian Singles Info-exchange (CSI) to release all information on My Profile Questionnaire to other members and potential members of CSI.  I do so realizing that CSI cannot guarantee that every member who selects me, or whom I select, will be of "good character."

I understand that I am under no obligation to meet with any other member, nor is any other member obliged to meet with me.  However, I agree to respond to all Selection Notices in a timely manner, and to treat all other members in a courteous manner.

I hereby agree that CSI is without liability under any circumstance, including but not limited to: the inadvertent release of confidential information, actions of other members, damage to reputation, or any other misfortune, even if such misfortune is caused by the negligence and/or fault of CSI. I hereby waive all claims against CSI, it's employees, agents, owners, directors and representatives.

SIGNATURE: _____________________. DATE: _________ 20____

Membership Level (For instructions refer to full version.)
     [_]Limited,   [_]Full,   [_]Unlimited

Mailing Instructions and Recommendations (For instructions refer to full version.)

For US Mail, send to:
       The Christian Singles Info-exchange
       5575 South Mosley Street
       Wichita, Kansas 67216-3631
Up to five sheets of 8½" x 11" paper can be mailed in a standard envelope at the one-ounce rate (42¢). Each additional ounce is 17¢s;.

For FAX transmission dial: 1-316-529-8900
The FAX line is open 24 hours a day. (It does NOT work well to FAX photographs.)

If paying your membership by credit card, please specify:
1. Type: [_]AmExpress,   [_] Discover,   [_] MasterCard,   [_] Visa
2. Your card no.:__ __ __ __ - __ __ __ __ - __ __ __ __ - __ __ __ __
3. The expiration date on the card. Valid THRU: _____ /_____
4. The three-digit security code from the back of your card: __ __ __
5. The total amount that you intend to pay: $____________.00