Scopus: Confidential Profile Form

PART I: Describing Yourself

First Name Last Name Sex Female Male Birthdate January February March April May June July August September October November December 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 Address City State ZIP Country E-mail address Are you employed? yes no --- Name of employer Your position Phone numbers (include area code) Day      Evening  Cellular Were you born Jewish? yes no --- If not, when and where did you convert?

Complete this section as it best describes YOU.

1. MARITAL HISTORY: never married widowed divorced If divorced: Have a Jewish divorce? yes no --- Was ex-spouse Jewish? yes no --- 2. CHILDREN: Have children? yes no --- If yes, how many? 3. SMOKING: no occasionally regularly 4. EDUCATION: Highest degree completed: High school Jr. College BA Masters Other (specify) Are you currently a student? yes no --- If yes, where 5. JEWISH IDENTITY: What term or terms would you use to describe yourself Jewishly? For example: Traditional, Secular, Orthodox, Spiritual, Reform, Cultural, Conservative, other... Do you attend prayer services regularly? yes no --- If yes, where Is Jewish learning part of your schedule? yes no --- If yes, describe 6. DIET: Do you keep kosher? yes no --- If yes, to what extent Are you a vegetarian? yes no --- If yes, to what extent 7. PETS: Do you have any pets? yes no --- If yes, describe Are you allergic to any animals? yes no --- If yes, explain 8. READING INTERESTS: List any newspapers/magazines that you read on a regular basis List 2-3 books that you have read recently 9. EXERCISE: Do you exercise regularly? yes no --- If yes, describe 10. TRAVEL: List any cities you visit on a regular basis List 3-4 of the most interesting cities/countries you have visited in the past 5 years 11. List 3-5 activities (not previously mentioned) that you enjoy. For example: concerts, dancing, museums, skiing, playing the piano, attending basketball games, camping, painting, computers, meditation, crossword puzzles, etc. (1) (2) (3) (4) (5) 12. List any social/political/volunteer/professional affiliations you have 13. HEIGHT 14. WEIGHT lb. kg

Part II: Describing the Person you would like to meet
	Most Preferable	Doesn't Matter	Absolute Rule-Out
1. Age Range	From To		Under Over
2. Living in these cities
3. Marital Status (never married, widowed, divorced)
4. With or without children
5. Smoking (no, occasionally, regularly)
6. Education
7. Jewish Observance

Part III

Make two suggestions for a first date

List some qualities that describe YOU: Your Values, Personality, and Physical Appearance

List some qualities that would describe the person you would like to meet:

Is there anything that hasn't been asked that you would like to add?

Part IV: Submitting the Scopus Confidential Profile Form

Please check your entries before submitting this form. Clicking on the button below will send the data you have entered directly to the Matchmaker. You can expect a telephone call within 2 to 3 weeks.

If you have a code, please enter it here: