APPLICATION FOR PERMISSION TO DATE MY DAUGHTER
NAME: _________________________________________________________ DATE OF BIRTH:____________________________ HEIGHT:_________ WEIGHT:________ I.Q.: _________ GPA: ________ COLLEGE AFFILIATION:_____________________ SOCIAL SECURITY #_________________ DRIVERS LIC/STATE:__________________ Boy Scout Rank: _________________ Home address: _______________________________ City/State/Zip: __________________________________________________ Name and address of Nearest Relative not incarcerated: ______________________ City/State/Zip:__________________________________________________ Church Membership: Date initiated:_______________ Attendance: _______________________ Annual Tithe: __________ circle one Do you have ONE MALE and ONE FEMALE parent? yes no If NO, please explain: ______________________________ Do you own a van? yes no Truck with oversize tires? yes no Waterbed? yes no Live in a trailer? yes no Do you have any of the following: [[circle any or all that apply]] earring nosering facial piercings naval piercings body piercings tattoo Do you have any relatives with the following: [[circle any or all that apply]] Heart disease mental illness living as a vegetable diabetes AIDS__ I.Q. of less than 50 missing teeth suffering from dwarfism/giantism addiction to alcohol/smoking/bowling/hunting_ In 25 words or less, what does LATE mean to you. ________________________________________________________________ In 25 words or less, what does ABSTINENCE mean to you. _________________________________________________________ In 25 words or less, what does "DON'T TOUCH MY DAUGHTER" ... mean to you ? _________________________________________ Please answer the following by filling in the blanks: All answers are confidential (Maybe) 1) If I were shot, the last place on my body I would want to be wounded is: ___________________________________________ 2) If I were beaten, the last bone I want broken is: ____________________________ Why?____________________________ 3) A woman's place is: ____________________________________________________________ 4) The one thing I hope this application does not ask me about is: ________________________________________________ 5) When I meet a girl, the first thing I notice is: __________________________ second thing I notice is: _________________ 6) What do you want to be IF you grow up? ____________________________________________________________________ Character: [it better be] Standing up for what you believe in, despite the personal cost. I SWEAR THAT ALL INFORMATION SUPPLIED ABOVE IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE UNDER PENALTY OF DEATH, DISMEMBERMENT, NATIVE AMERICAN ANT TORTURE, CURCIFIXION, ELECTROCUTION, CHINEESE WATER TORTURE, DRAWING & QUARTERING, AND RED-HOT POKERS. X_________________________________________________ Signature Thank you for your interest. Please allow 4-6 years for processing. Don't call us, We'll call you. Any mis-truths will disqualify you from apply again for 10 years. NOTE: This application will be incomplete and rejected unless accompanied by a complete income statement, job history, lineage, and current medical report from your doctor.
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