Name:_____________________________________________________________________
                        First                                             M.I.                       Last

Address:___________________________________________________________________
                      Street                                   City                            State/Province                                    Zip Code

Age:________________. Phone #:_______________________________________________

[   ] Male        [   ] Female              Height:_____________    Weight:____________

 [   ] Smoker         [   ] Non Smoker      [   ] Social drinker      [   ] Non Drinker

Please List your activities: _____________________________________________________

_________________________________________________________________________
write as much information about yourself as possible,
such as special interests, past careers,  Hobbies, etc._________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________
If more space needed, use the back of the form after printing it.

How did you find out about Retired Singles ?_____________________________________

Please mail $80.00 check or money order payable to Retired Singles, Inc.   P.O. Box 518 -
Yucaipa, CA 92399 - Attn: Website Special.

All Information  contained in this form is confidential and will not be sold to mailing list companies
or other entities. Please allow two to four weeks for processing.

* I will not hold Retired Singles responsible for any dealings between me and the persons I
contact or who contact me through Retired Singles.

Signature:_______________________________________ Date:______________________