Name
First Name
Last Name
Spouse Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
-
Area Code
Phone Number
How many years of marriage?
Please Select
0-5 years
6-10 years
11+
How often do you date?
Please Select
0-1 a month
2-5 a month
6-10 a month
What’s a date?
Need help with dates
How many kids?
Please Select
0
1
2
3
4
5
Would you like to date more?
Yes, We need to date more
No, We are good in the dating dept
How much more would you like to date?
Please Select
Double up on our dating
Date period
We are cool in the dating game.
Other
What are some of the things that makes dating difficult? You can choose more than one answer
Reliable and affordable babysitter
Money is funny. Dating cost too much
Lack creativity
Too busy with the hustle and bustle of life
Have you ever attended a Marriage Retreat?
Yes
No
Do you believe your dating habits need a boost?
Please Select
yes
no
we are good for now
Submit
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