Confidential Questionnaire

Surname:          
Given Name:       
Address:          
     (include suite or apartment number)
City:             
Province/State:   
Country:          
Postal/Zip Code:  
Telephone:        
     (include area code)
Fax:              
     (include area code)
E-mail address:   
Date of Birth:    

Your Hebrew Name:     
Father's Hebrew Name: 
Mother's Hebrew Name: 
Mother's Maiden Name: 
Maternal Grandmother's Maiden Name: 

For men only:

I am a     Kohen    Levi    Yisroel

Name of Rabbi and Synagogue where I attend:

Rabbi:      Since:  Telephone: 
Synagogue:  Since:  Telephone: 

Please list two personal references:

Name:  Telephone: 
Name:  Telephone: 

ABOUT ME	ABOUT MY BASHERT
Marital Status
Single Widowed Divorced Separated	Single Widowed Divorced
If divorced:	Any of the above
Civil GET
Place of GET: Date:
Rabbi:
Children
None Yes Number:	None Yes Number:
Ages:	Age Range:
	Not important
Personal Particulars
Age:	Age Range:
Weight:	Weight Range:
Height:	Height Range:
Religious Status
Orthodox Modern Orthodox Yeshiva Oriented	Orthodox Modern Orthodox Yeshiva Oriented
Chassidic Specify:	Chassidic Specify:
Other Specify:	Other Specify:
Jewish Observance
Observant from birth	Observant from birth
Baal Tshuvah years	Baal Tshuvah
Converted Place: Beth Din/Rabbi: Date:	Converted according to Halachah
	Any of the above
Secular Education
Elementary High School University	Elementary High School University
If University, degree achieved:
None Bachelors Masters Doctorate	None Bachelors Masters Doctorate
	Not important
Jewish Education
Adult Education Evening School Day School	Adult Education Evening School Day School
If Yeshiva:
Elementary High School Advanced	Elementary High School Advanced
Other Specify:	Not important
Employment
Full time, Occupation:	Work full time
Part time, Occupation:	Work part time
Student, Studying:	Student
Self-employed, Activity:	Self-employed
Retired, From:	Retired
Other, Specify:	Other, Specify:
	Professional
	Not Important
Spare Time is Spent
Learning Reading Sports activities Socializing Cultural events	Learning Reading Sports activities Socializing Cultural events
Other, Specify:	Other, Specify:
	Not Important
Languages Spoken
English Hebrew Yiddish	English Hebrew Yiddish
Other, Specify:	Other, Specify:
About Smoking
Non-smoker Smoker	Non-smoker Smoker
Do not mind smoke	Do not mind smoke
About Drinking
Never L'chaim Socially	Never L'chaim Socially
About Relocating
Not a problem A possibility Not possible	Willing to relocate Does not matter
I am considering making Aliyah	Will consider making Aliyah
Physical / Mental Challenges
No	No
Yes Specify:	Yes Specify:
Medication

Additional Information

Parents

Are they both alive?    Yes    No 
How many years have they been married?   
Are they frum?    Yes    No
Are they retired or do they work?    Retired    Work
Where were they born? (Father / Mother)
 

Siblings

Do you have any brothers or sisters?    Yes    No
Are they frum?    Yes    No
Are any married?   
Are any divorced?   
Are any single?   

Would you cover your hair?    Yes    No
Wear a sheitel?    Yes    No
What schools did you attend?
 
Are you interested in marrying a "Kohen"?    Yes    No    Not important
How would you prefer your husband cover his head?
  Yarmulke always    Yarmulke Shabbos  Hat everyday    Hat on Shabbos
Are you interested in someone bearded or clean shaven?
  Bearded    Clean Shaven    Not important

How many times a day do you daven?   
Do you wear a yarmulke at work?    Yes    No
Do you wear a hat on Shabbos?    Yes    No
 What Yeshivas (if any) did you attend?
 
How should your wife cover her hair?
 

Dating

How many people have you seen in the last year?   
How many more than three times?   
What turns you off when you meet someone?

Where were you born?   
 For how many years have you worked at your present job?   
Have you ever been promoted there (if applicable)?    Yes    No

Divorced clients only:

How long were you married?   
What in your opinion went wrong?






Divorced and widowed clients only:

Are your childred frum?    Yes    No
How many times have you been married?   

1. Do you:

   a. Watch TV	Yes Never Sometimes
   b. Go to movies	Yes Never Sometimes
   c. Eat fish, dairy or salads at a non-kosher restaurant	Yes Never Sometimes
   d. i. Women Only - Wear pants	Yes Never Sometimes
   d. ii. Men only - Want your wife to wear pants	Yes Never Sometimes
   e. Mix dance	Yes Never Sometimes
   f. Mix swim	Yes Never Sometimes

Help us to understand you

1. What strong points are you looking for in a spouse?
   
   
   
   

   
   

2. Write a paragraph describing your personality:
   
   
   
   
   

Payment Method:

I wish to pay my processing fee of $180.00 as follows:

1. By Visa:
   Complete Name on Visa Card:
   Visa Number:
   Expiry Date:
   Issuing Bank:
2. By cheque or money order sent by courier or by mail to Orthodox Connection main office. (You can find our address all over this Website.)