This application must be answered in full prior to permission being granted to date my daughter. Remember all answers will be checked for valid responses. Please consult your life insurance agent to verify that all beneficiaries are current and additional coverage is applied for if needed prior to turning this application in.

Name:_________________     Date of Birth:___________________
Home Address:_______________________________ City:__________ 
State:_________ Zip:___________
Social Security #:________________________________  
Drivers License #:________________________________
Height:_________  Weight:__________ 
I.Q.:________ G.P.A.:___________
Boy Scout Rank:_____________

1. Do you have one male and one female parent? (Yes / No)

If no, explain: ____________________________________________

2. Do you own a van? (Yes / No)
   a truck with over-sized tires? (Yes / No)
   a waterbed? (Yes / No)
(Note: if you answer yes to any of #2, put down your pencil,
discontinue application, and leave premises)

3. In 50 words or less, what does LATE mean to you?_________
____________________________________________________________
____________________________________________________________
____________________________________________________________

4. In 50 words or less, what does DON'T TOUCH MY DAUGHTER 
mean to you? _______________________________________________
____________________________________________________________
____________________________________________________________

5. In 50 words or less, what does ABSTINENCE mean to you?_
____________________________________________________________
____________________________________________________________
____________________________________________________________

6. Do you have an ear ring, nose ring, belly-button ring or 
tattoo? (Yes / No)
(Note: if you answer YES to any of #6, put down your pencil,
discontinue application, and leave premises).

7. Church you attend: (Yes / No)
   How often do you attend?_________

8. When would be the best time to interview your father, 
mother, priest/pastor?
___________________________________________________________

9. Answer by filling in the blank. Please answer freely - 
all answers are confidential.
(That means I won't tell anyone - ever - I promise.)
      
      A. If I were shot, the last place on my body I would 
	 want to be wounded is in the _____________________
      
      B. If I were beaten, the last bone in my body I would 
	 want broken is my ________________________________
      
      C. A woman's place is in the ________________________
      
      D. The one thing I hope this application does not 
	 ask me about is ___________________________________
	
      E. When I first meet a girl, the first thing I 
	 notice is her _____________________________________
(Note: If answer E begins with "T" or "A", put down your 
pencil, discontinue application, and leave premises - keeping 
your head low and running in serpentine fashion is advised.)

10. What do you want to be IF you grow up? 
_____________________________________________________________

I SWEAR THAT ALL INFORMATION SUPPLIED ABOVE IS TRUE AND 
CORRECT TO THE BEST OF MY KNOWLEDGE; UNDER PENALTY OF DEATH, 
DISMEMBERMENT, NATIVE AMERICAN TORTURE, CRUCIFIXION, 
ELECTRICUTION, CHINESE WATER TORTURE, AND RED-HOT POKERS.