QUESTIONNAIRE - FORM A  (To be filled in by the Enquirer in block letters for the information of the Bureau only)


SURNAME: Mr./Mrs./Miss


CHRISTIAN NAMES:


ADDRESS:


Phone number:

Email address:

NAME OF CHURCH ATTENDED:


NAME OF PARISH:


DATE OF BIRTH:


COUNTY OF BIRTH:


HEIGHT:


EDUCATION:


NATURE OF EMPLOYMENT OR OCCUPATION:


(Salary or Income or size of Farm)


INTERESTS, HOBBIES, & PASTIMES:


(Do you like Music, Dancing, Sport, etc?)


HEALTH:


PHYSICAL DISABILITIES OR DEFORMITIES, IF ANY:


WERE YOU PREVIOUSLY MARRIED?:


KIND OF PARTNER SUGGESTED - AGE LIMIT, TYPE OF OCCUPATION ETC.:



ANY OTHER INFORMATION ABOUT YOURSELF:

(To help us in our advertising we would like if you would specify the name of the newspaper, magazine, website, TV or Radio Programme in which you became aware of the Bureau.)

PLEASE ENCLOSE WITH THIS QUESTIONNAIRE A CLEAR PHOTOGRAPH TAKEN WITHIN THE LAST TWELVE MONTHS AND NOT LARGER THAN POSTCARD SIZE.

DECLARATION

I declare that I have read and understood the particulars and conditions of the Bureau and that the information I have given above is, to the best of my knowledge, correct.

I further declare that I am a regular and practising Catholic. I affirm that I am free to marry, and that my motive in seeking the services of the Bureau is entirely honourable.

I understand that I alone be held responsible for my conduct towards the person or persons to whom the Bureau introduces me.



Signature: ---------------------------------------------------------------------------------------

Date: ---------------------------------------------