Match-making Registration

Please complete the following form. We will respond quickly, usually within two working days.

First name*:
Last name*:
Programme*:		Select one Gold Match-making Programme Personalised Relationship Coaching Great Connections Events Great Connections Seminars Free Singles Database All Programmes Unsure
Referred by:
Suburb:
City*:
Phone*:
Mobile:
Email*:
Gender*:		Female   Male
Hair color*:		Select one Black Blond Brown Red Grey Balding Bald
Eye color*:		Select one Black Blue Brown Green Hazel
Birth date*:		01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990
Height*:		Select one <150 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 >220 cm       Conversion Chart
Weight*:		Select one <45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 >150 kg       Conversion Chart
Body Type:		Select one Muscular Athletic Lean Average Curvaceous Very Curvaceous Overweight
Ethnicity*:		Select one New Zealand European White European White North American Maori Pacific Island Asian Hispanic Non-white European Non-white North American African Other
Income range*:		Select one $0 - $20,000 $20,001 - $30,000 $30,001 - $40,000 $40,001 - $50,000 $50,000 - $75,000 $75,001 - $100,000 $100,001 - $125,000 >$125,000
Financially, I am*:		Well off Secure Making ends meet Struggling
Smoking*:		Select one I do not smoke I smoke socially I smoke daily I smoke a half pack a day I smoke a pack a day I smoke two packs a day or more
Alcohol consumption*:		Select one Never Once a week A few times a week Daily
Marital status*:		Select one Single, never married Married, separated Married, together Divorced Widowed
Separation date (if applicable):		01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 1960 1961 1962 1963 1964 1965 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Relationship status*:		Select one Unattached Casually dating one person Casually dating multiple people Steadily dating one person Partnered
Education*:		Select one No college Some college Graduated college Some university Graduated university Some post-graduate work Graduate degree
Occupation*:
Employer:
Position/Title:
Describe your job*:
Do you like your job?*		Select one Yes Usually Occasionally Rarely No
*I have		Select one 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 sons aged and Select one 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 daughters aged
*I want		Select one 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 more children
Hobbies & Interests*:
Number of pets:		0 1 2 3 4 5 >5
Pets (describe):
Religion*:		Select one Agnostic Atheist Buddhist Christian - Catholic Christian - Episcopalean Christian - Fundamentalist Christian - Protestant Christian - Other Hindu Jewish Mormon Muslim None No formal religion Other
Religious perspective:
Comment:
Relationship goal*:		Select one Friendship Friends with benefits Casual relationship More-than-casual relationship Partnership - short-term Partnership - long-term Marriage
What I seek in a relationship*:
What I seek in a partner*: