I am dead - Lord have mercy I will be using this on my next potential Boyfriend

Name

Last
First
Middle

Address
City
State
Zip

Telephone:
Home #

Work#

Cell#


Date of Birth:

Age

SS#


Weight

Height



Ethnicity: (check)
Black

Hispanic

White

Other





Do you live with any of the following: (circle)

Grandmother
Parents
Mother
Father
Girlfriend
Baby Mama
Alone
Shelter
Wife
Auntie
Other




Any Children (circle yes or no)


Yes
No
If yes, how many


How many Baby Mamas?

If more than one, please name below.
Use separate sheet of paper if need more room.

1.

2.

3.


Ever been married (circle )
Yes
No
If yes, how many times?


Are you or have you ever been on the Down Low? (circle one)
Yes
No
(If you answer "Yes" STOP RIGHT HERE!!)

Do you owe child support?
Yes
No
Don't Know


*If your ex-wife is getting state benefits (childcare, food stamps, etc), then you owe somebody something. Especially tax payers. Stop here and go take care of your dang kids.



Education:

Did you graduate from high school? (circle )
Yes
No
Name of high school (if yes)


Have you received any of the following? (Circle One)
GED
Diploma
Nothing

*If you did not complete any of the above, please Stop here and return to school.

Any college? (circle one)
Yes
No
Still Enrolled:
Yes
No
Graduated

Have you ever been to jail? (circle one)
Yes
No
If yes, what for? (be very specific)




Have you ever been to prison? (circle one)
Yes
No


*If you have answered yes to the above question, please Stop here and call your P.O. immediately.

Employed? (circle)
Yes
No
*If no, please Stop here?



If yes, where and how long?


Do you have health insurance?
Yes
No





When did you last visit the dentist?


When was the last time you have been to the doctor? _
Yes
No
What for?


List any (all) illnesses. Use separate sheet of paper if needed.

Do you have or have you had any of the following? (please circle all that may apply)

Hepatitis

A or B or C
Herpes
Mononucleosis
HIV/AIDS
The Bird Flu
West Nile Virus
Crabs

Chlamydia
Gonorrhea
SARS
Head Lice
Ringworms
Boils
Sex Change

Shingles
Meningitis
Measles
Mumps
Ebola
Bunions
Virus
A Cold
Something that you can't spell:



*If you have circled any of these, Stop here do NOT turn in your application. See the doctor immediately!

Do you or have you ever used (ingested in any way) any of the following: (circle all that apply)

Crack/Cocaine
Heroin
Paint Markers
Ecstasy
Glue
Bad pills
Snuff

Anything under the kitchen sink



*Please use a separate sheet of paper to compile a list of goals and accomplishments.

By signing below, you agree that all of the information given above is true to the best of your knowledge. For my protection, you may be asked to provide the following information upon request: state ID, birth certificate, recent payroll stub, a recent clean bill of health from a certified physician or practitioner.

Falsifying information may result in termination of this relationship (if applicable), and a severe a** whooping by my project cousins Pookie, Ray-Ray, Darnell, Lil Krazy or all of the above.





Applicants Signature
Date:

Print Name :