Exclusive Single Mingle Speed Dating Network Registration Questionnaire (F)

The Exclusive Single Mingle (ESM) is a virtual speed dating network that brings together North Carolina professionals. ESM provides a safe environment for our members to meet other singles, in the comfort of their own home. ESM prides itself on keeping your personal identifiable information secure. No other members will have access to the information that you share with us.

Once our singles match, an email address is the only contact information that will be shared. ESM secures your privacy and makes your speed dating experience comfortable, safe, fun, and welcoming.

STEP ONE: Registration & Singles Questionnaire
o Help us get to know your significant other preferences for future
speed dating events.
o It’s free to register!
o After you register and complete questionnaire you will be notified on next steps.
o Single does not proceed to step two (screening process) if they did not meet requirements for registration.

STEP TWO: Screening Process
o We pride ourselves on confidentiality when conducting screenings.
o We conduct screenings to make sure the singles participating in our events are legitimate and meet our guidelines.
o Our screening process ONLY if you met requirements from registration, consists
of:
▪ 1 virtual screening with speed dating staff to confirm identity (identification card, screening questions, and review dating preferences)
▪ Provide a recent work resume
▪ Referral priority (Begins spring 2023)
o Screened Singles Outcomes (3 options)
- Approved: When screening process is completed, and the single has
been accepted to move forward, they will pay fee for upcoming speed
dating event. They will also remain on email list for future dating
opportunities in our network.
OR
- Approved for Waitlist: When screening process is completed but the
single does not qualify for the upcoming speed dating event (due to
capacity and matches). No fee is required. They will remain on email list for future dating opportunities in our network.
OR
- Not approved: Single did not meet the minimum requirements during
the screening process to participate in our network at this time.

STEP THREE: Speed Dating Event Confirmation
o Accepted and approved singles will receive virtual or in-person speed dating events date/time.
o Singles are asked to arrive 20 minutes before event time.
o Score cards are provided for each single to rate their date.
o Singles will attend 5 dates during speed dating event
o Additional instructions will be given before event and the day of.

Contact information (private and will not be shared with others) *

First Name Last Name

What is your sex? *

Female Male

City *

The same on your ID

State *

The same on your ID

Phone Number *

Please enter a valid phone number.

E-mail *

example@example.com

What is your body type? *

Slim Average build Athletic build Curvy Heavy set

What is your perspective partners body type (select all that apply)? *

Slim Average build Athletic build Curvy Heavy set

What is your age? *

Which age range do you prefer for your perspective partner? Select all that apply. *

21-24 25-34 35-44 45-54 55-64 65+

Select your income range: *

Below $40,000 $41,000-$50,000 $51,000-$60,000 $61,000-$70,000 $71,000-$80,000 $81,000-$90,000 Over $91,000 Currently no income

Which income range do you prefer your potential partner to have? Select all that apply. *

Below $40,000 $41,000-$50,000 $51,000-$60,000 $61,000-$70,000 $71,000-$80,000 $81,000-$90,000 I don't care

Select your race. Select all that apply: *

White or Caucasian Black or African American Hispanic or Latino Asian or Asian American American Indian or Alaska Native Native Hawaiian or other Pacific Islander Another race

Select your race preference for perspective partner. You can select multiple. *

White or Caucasian Black or African American Hispanic or Latino Asian or Asian American American Indian or Alaska Native Native Hawaiian or other Pacific Islander Another race

Do you have children? *

Yes No

Are you okay if your perspective partner has children? *

Yes No

What is your marital status? *

Single never married Married Divorced Widowed Separated

Select two of the most desired qualities in a perspective partner: *

Financially Responsible Education Sense of Humor Emotionally Supportive Traditional Gender Roles Spirituality

Pick one flaw that would be most tolerable to you from a perspective partner (this will help determine your speed dating matches): *

Bad Money Management Low Sex Drive Selfishness Poor Communication Skills

Please upload your most recent work resume. This is part of our screening process. *

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Exclusive Single Mingle Speed Dating Network

Help us get to know your significant other preferences for future speed dating events. We cater to single urban professionals (heterosexual relationships).