Information Survey

The purpose of this survey is to collect information from you about yourself. We will inform our available members to contact you or you will be notified of your dating partner/partners.

This survey is divided into the following sections:

Fill out the information in each section as requested. Then at the end of the form supply your name and contact information, and submit the form. You will receive a confirmation message from us shortly.

SECTION A -- Dating Info

You first have to promise to tell the truth and nothing but the truth.

  1. Who would you like to go out with ? (Mutiple partners are also accepted)



  2. When would you like to go out ?:

    Morning Noon Afternoon Evening Night Midnight

  3. We would like to send you some information. What is your mailing address? 
    Name     
Street   
City     
State    
Telephone
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SECTION B -- Destination Anywhere

These are the instructions for filling out this section. These are the instructions for filling out this section. These are the instructions for filling out this section.

  1. How would you rate this survey?

    Bad Poor Fair Good Excellent

  2. What is your favorite color?



  3. Select the subject areas you are most interested in:

    Shopping
    Skating
    Window Shopping
    Lepakking
    Business

  4. Where do you plan to go ?:

    Place
    Time & Date
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SECTION C -- Side Orders

These are the instructions for filling out this section. These are the instructions for filling out this section. These are the instructions for filling out this section.

  1. Which of the following is provided ? 
    Transport  Booking    Guys       Handphone
Money      Excitement Clothes    Pager
Food       Girls      Bodyguard  Entertainment
  2. What are you planning to do ?:



  3. Select a month from the following list, which you want to go out:

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FORM SUBMISSION

Thank you for taking the time to answer the questions in our survey.

I guess you know the prosedures. We will get back to you ASAP. You will not regret and have a time of a lifetime.

Thank You for your co-operation

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SECT.
Copyright © 1998 5 Harapan. All rights reserved.
Revised: May 17, 1998.