How did you find out about us? (Optional)

Section 1

General Information

101. Member Number: (or check below)

I do NOT have a Member Number yet. (If left blank, CSI will assign a number.  This number must agree with the number on the Contact Information blank above.)

102. Gender: Male, Female

103. Category: (Check only one number.)

1.TEEN with no previous marriage; age 16 thru 20.
2.ADULT with no previous marriage; age 21 thru 54.
3.PREVIOUSLY MARRIED; age 16 thru 54.
4.SENIOR; age 55 and better.

Divorced Widowed Never married
(check each applicable block.)

104. I was previously married time(s). (Enter "0" if never married.)

105. Birth date: / / . (mm/dd/yyyy)  (Birthday is required.)

106. My religious denomination is: (Check only one.)

107. My race is: (List the general group you identify with, specific ethnic background is in section 2.)

108. I am approximately 2ft 1in = 25in 2ft 2in = 26in 2ft 3in = 27in 2ft 4in = 28in 2ft 5in = 29in 2ft 6in = 30in 2ft 7in = 31in 2ft 8in = 32in 2ft 9in = 33in 2ft 10in = 34in 2ft 11in = 35in 3ft 0in = 36in 3ft 1in = 37in 3ft 2in = 38in 3ft 3in = 39in 3ft 4in = 40in 3ft 5in = 41in 3ft 6in = 42in 3ft 7in = 43in 3ft 8in = 44in 3ft 9in = 45in 3ft 10in = 46in 3ft 11in = 47in 4ft 0in = 48in 4ft 1in = 49in 4ft 2in = 50in 4ft 3in = 51in 4ft 4in = 52in 4ft 5in = 53in 4ft 6in = 54in 4ft 7in = 55in 4ft 8in = 56in 4ft 9in = 57in 4ft 10in = 58in 4ft 11in = 59in 5ft 0in = 60in 5ft 1in = 61in 5ft 2in = 62in 5ft 3in = 63in 5ft 4in = 64in 5ft 5in = 65in 5ft 6in = 66in 5ft 7in = 67in 5ft 8in = 68in 5ft 9in = 69in 5ft 10in = 70in 5ft 11in = 71in 6ft 0in = 72in 6ft 1in = 73in 6ft 2in = 74in 6ft 3in = 75in 6ft 4in = 76in 6ft 5in = 77in 6ft 6in = 78in 6ft 7in = 79in 6ft 8in = 80in 6ft 9in = 81in 6ft 10in = 82in 6ft 11in = 83in 7ft 0in = 84in 7ft 1in = 85in 7ft 2in = 86in 7ft 3in = 87in 7ft 4in = 88in 7ft 5in = 89in 7ft 6in = 90in 7ft 7in = 91in 7ft 8in = 92in 7ft 9in = 93in 7ft 10in = 94in 7ft 11in = 95in 8ft 0in = 96in 8ft 1in = 97in 8ft 2in = 98in 8ft 3in = 99in tall, and my body build is:

109. I have completed years of Education. (Enter total number of years, but do not include preschool nor kindergarten. Include all years after high school including trade schools.  If you graduated from high school in less than twelve years, enter twelve plus any additional years.)

110. I have the following diplomas, degrees and/or professional licenses:

111. My current primary job or occupation:

112. My secondary job or occupation, including volunteer work: (You may list more than one.)

113. My residential Zip Code is , (five digits only) and the city associated with this zip code is .

My residence is:

1. owned by me alone. (Disregard mortgage.)
2. owned in part by me.
3. rented by me alone.
4. rented with a roommate.
5. my parent's residence.
6. other (specify): .

114. I HAVE living child(ren). (Enter number; "0" if none.)

Their age(s) is/are:
.

115. I LIVE WITH child(ren) or other DEPENDENT(S).  (Include retired parents, but do not include persons who are not your dependent. Enter "0" if none.)

Their relationship to me is, and their age is: (example: "Son - 11; Grandmother - 92")
.

Section 2

Background information

201. My ethnic background is: (You may use combinations like "Scot/Irish" or "Unknown".  It is not necessary to put exact percentages or fractions.)

Country (Mother): .
Country (Father): .

202. I grew up in the state or foreign country of , and I lived primarily

in a large City. (Approximately 50'000 or more)
in a small Town. (Approximately 50'000 or less)
on a Farm.
in some combination of the above, or "Other".

203. I grew up with sister(s), and brother(s), (enter "0" if none,) and I:

1. was the OLDEST or ONLY child my parents had.
2. was neither the OLDEST nor the YOUNGEST child.
3. was the YOUNGEST child in my family.
4. had a combination, due to a blended family.

204. 0 1 2 of my parents are living, and:

a. are still married, or, remained married until the death of one or both.
b. are separated or divorced, or, were apart prior to the death of one or both.

205. I served in the military for years, ("0" if none,) and I (leave blank if "0" years served.)

am still on Active duty.
have an Honorable discharge.
have an other-than-honorable Discharge.

My branch and primary military occupation was (is): .

206. I have traveled to different states, and different countries. (Enter approximate number if exact number is unknown. Enter "0" if none. It is O.K. to count U.S. territories as states.)

207. My Political outlook has generally been: (Check only one.)

208. Concerning major permanent physical disabilities: (Check only one.)

1. I have NO permanent physical nor emotional disabilities that limit my mobility or my ability to work.
2. I have a permanent disability, however, I am NOT dependent upon others for mobility and care. (Comment below as desired.)
3. I am dependent and/or confined. (Comment below as desired.)
Optional comment: .

209. Concerning tobacco, for the past year I have been a: (Check only one.)

1. non-smoker and a non-chewer.
2. light smoker and a non-chewer.
3. heavy smoker and non-chewer.
4. chewer, but I don't smoke.
5. smoker and a chewer.

210. Concerning alcohol, I: (Check only one.)

1. have always been a non-drinker.
2. am now a non-drinker, past drinker.
3. limited user, on rare occasions.
4. regular user, on weekends & holidays.
5. daily or near-daily user.

211. I have DUI/DWI or other alcohol related conviction(s) on record. (Enter "0" if none.)

Optional comment: .

212. I have felony conviction(s) on record. (Enter "0" if none.)

Optional comment: .

Section 3

Values & Attitudes

There are no "right" or "wrong" answers in this section. Answer each as follows:

Enter 1, if you STRONGLY AGREE and are INFLEXIBLE about it.
Enter 2, if you AGREE but you could be FLEXIBLE about it.
Enter 3, if you feel NEUTRAL about it.
Enter 4, if you DISAGREE but you could be FLEXIBLE about it.
Enter 5, if you STRONGLY DISAGREE and are INFLEXIBLE about it.

301. Married people should keep separate financial accounts.

302. A married mother of young children should not work outside the home.

303. Married men should share the housework if both the husband and the wife work outside of the home.

304. Having more than one "general use" credit card per person, in addition to "special use cards", store cards, and discount cards, is a bad idea.

305. The man should always drive.

306. Pets should never be allowed in the house.

307. Borrowing money for a vacation is O.K. if there is no other source of money.

308. In some situations and circumstances, little white lies are better than the cruel truth.

309. Smoking should not be allowed in the house.

310. Physical discipline, such as spanking, is an acceptable method of child discipline.

311. Children should be sent to a private school if the parents can afford it.

312. Meals should be prepared by the wife on a regular schedule, except for special occasions.

313. There should be no guns in the house.

314. A married person should never take a job that requires them to be away from their family for extended periods of time.

315. On a date, the man should always pay.

316. Eating out at expensive restaurants is basically a waste of time and money.

317. Using a little marijuana now and then is O.K.

318. The entire family should attend church services regularly.

319. The church has "no business in the bedroom," concerning contraceptives.

320. Charitable donations, i.e., tithing 10% of one's income should come before family and personal expenses.

321. How many children to have, if any, is primarily a decision for the wife.

322. Dancing is great entertainment for married couples.

323. You don't have to be "on-time" for everything.

324. The TV should be OFF at meal time, when two or more family members are having a meal together.

325. A woman should dress and groom herself in a way that is pleasing to her husband.

326. I'd consider moving to another state, if my family would be better off financially.

327. It is O.K. to play practical jokes on one's spouse.

328. My spouse could have close friends of the opposite sex who are not friends of mine.

329. I'm the type of person who would enjoy going to a class or family reunion.

330. A man should not do women's work, and a woman should not do a man's job.

331. The family should read scripture and/or pray together every day.

332. Watching sports on TV is time well spent.

333. It would be O.K. for my spouse to ask me to tell a lie for him or her.

334. Infidelity alone, is grounds for a separation.

335. Photographs of old boy/girl friends or past spouse, should be destroyed after a couple gets married.

336. Vacations should be spent living spontaneously, rather than to a planned schedule.

Section 4

Life Style & Future Plans

401. After I get married, I: (Check only one.)

402. My dream home would be located: (Check only one.)

403. Concerning children, after I get married, I: (Check one number and one letter as applicable.)

404. After I get married, I: (Check only one.)

405. My total time spent watching TV averages about 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 hours per day. (Use nearest whole number. Do not use fractions nor decimals. If less than 1/2 hour per day, enter "0".)

406. I am usually a: (Check only one.)

407. I would rather spend my free time: (Check only one.)

408. My favorite music is (You may check more than one.)

409. Some of my favorite activities are: (Check all that apply.)

501. Use this space to expand on questions that need further clarification or comment. (Refer to the question number you are commenting on. If space is available here, you may use it for "general comments" about yourself, i.e. characteristics not already covered by a question.)

502. I am looking for a person who has the following characteristics and traits: (Preferences)

I am looking for a person who

Reverse Narrative

(This section is optional; it restricts your file to only those members who meet your standards.  If you DO NOT want to be bothered by being selected by someone who doesn't meet certain standards, i.e. age, religious denomination, race, education, etc., list those characteristics here.  These are ABSOLUTE restrictions, not mere preferences.)

503. I do not want to be selected by anyone with the following characteristics:

Section 6

Photograph Information and Notes

Adding a photo to your profile is optional.  ADDING YOUR PHOTOGRAPH TO YOUR PROFILE DOES NOT CHANGE THE COST OF YOUR MEMBERSHIP.  A photo is recommended because photo-profiles have more activity than no-photo-profiles.  (About 95% of all profiles in our system contain a photograph.)

Since first impressions are important, CSI recommends that you include a good picture of yourself that is no more than a few years old, ...the more recent, the better!

You can send your photos electronically after you submit your profile or through US Mail

If sending your photo by US Mail, simply write your name on the back of the photograph and send it to:

The Christian Singles Info-exchange
5575 S Mosley Street
Wichita, KS  67216-3631

NOTE: If you don't have a suitable studio portrait of yourself, you may send any photograph or snap-shot that you desire.  We can scan and re-size anything from a small postage-stamp-size photo to an 8 X 10 picture.  If the photo contains images of other people, be sure to let us know which one is you, we will frame only you, unless you specifically want your children, pets, others, or objects to appear on the Profile Print-Out picture with you.  If you enclose more than one photo, CSI will scan and install the one that we deem to be the best suited for use on your Profile Print-Out.

601. Year photo was taken: (Disregard Month and Day) .

602. Optional comment about the photo(s): (Include a brief photo description)
.

Section 7

Membership Agreement

(CSI membership cannot be completed unless Profile Questionnaire 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.

701.
SIGNATURE:   MONTH   DAY   YEAR

702. Your data will be entered into the CSI system, and a correction copy will be mailed to you at: