Post Your Profile

Please fill out the form below to help us develop your profile.

Name:


First Name	Middle Name	Last Name

Email:

Address:


Street/PO Box

City,	Sate	Zip Code

Phone:

Physical Attributes:

		' "
Sex	Age	Height

Weight	Hair Color	Eyes

General Health Condition:
(Physical Defects)

Education:
(select highest)

8 9 10 11 12
College 1 2 3 4 5+
Certificate or degree earned:

Occupation:

Previous Occupations:

Religion:

Name of church:

I engage in religious worship:

Never
Holidays Only
Every Month
Every Week
Every Few Days
Every Day

Race/Ethnic Background:

Marital Status:

Never Married
Legally Separated
Divorced
Widow(er)

I live:

Alone
With Parents
With Roommates
With Children
Boys Ages
Girls Ages

I prefer not to date:
(Select any you will not date)

Whites
Blacks
Orientals
Other Asians
Hispanics
Middle Easterners
Indians

I will not date:
(Select any you will not date)

Catholics
Protestants
Jews
Asian Religions
Nonpracticing
Athiests

I smoke:

Regularly
Occasionally
Never

I use:

A Pipe
Cigars
Cigarettes
Smokeless Tobacco

I use alcohol:

Regularly
Socially
Seldom
Never

I prefer to date a person who uses alcohol:

Regularly
Socially
Seldom
Never
Doesn't Matter

The area where I live can be described as: (Select all that apply)

In the Country
On a farm
Forest area
Plains area
Mountain area
Near ocean
Town/City (Popularion: )

I would like to live: (Select all that apply)

In the Country
On a farm
Forest area
Plains area
Mountain area
Near ocean
Town/City (Popularion: )

Farming:
I am
I would like to be

Full-time farmer
Part-time farmer
Hobby farmer

I am willing to relocate:

Yes No

My livestock interests include:

Beef
Dairy
Sheep
Goats
Horses
Pork
Poultry
Other

Crops I raise include:

My hobbies are:

My leisure interests are:

My attributes and/or goals are:

On a date, I prefer to:

I prefer to date somone ages:

I prefer someone who:

Furthest I prefer to travel for a date:

Comments:

Times I prefer to date are:

How did you hear about Country Connections?

(If publication or website, please specify)

Have you previously subscribed to Country Connections?

Yes No

When did your last subscription expire:

Giving False Information (such as distorting your age, height, weight, marital status, education or occupation)or making improper use of your subscription will result in termination of your subscription without a refund.

Other information that I feel will be helpful:

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