Name (Print)  ____________________________________________________   Sex: M/F  ___

Nationality: ______________________________________________________   Birthdate:/M____ /D_____ /Y_____

Height:______________ Weight::_________________

Telephone  Home: _________________ Work: _________________________E-mail Other:_______________________

Home Address: _________________________________________________________________________________

Work Company Name: __________________________________________________________________________

Title/Position: ______________________________________________________Salary(Optional):____________

Education:___________________________________________ Degree:__________________________________

Ever Married:  Yes/No ______

With Children: Yes/No ______

Hobbies :_____________________________________________________________________________________

_____________________________________________________________________________________________

Looking for a person

Nationality: American /Asian /Both /Other :______________________

Age Range :__________________________ Height Range :____________________________

Other Requirements :__________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

This is to certify that the information submitted herein to ASIAN & AMERICAN by applicant, the undersigned, is true and accurate. It is applicant's responsibility to update and maintain accuracy of the information kept on file. Applicant fully understands that successful meeting and relationship with other club members entirely depend upon applicant's personal character, social skills, etc. It is also applicant's own discretion and responsibility in establishing such social contacts. Applicant agrees that ASIAN & AMERICAN offers no safety of member's private social contacts, and shall not be held liable for any inaccuracy of the information provided by its club members, and the membership fee is not refundable.

Signature: ____________________________________________________________________________________

Date: /M ____/D_____ /Y_______

Memberships Fee $ 200.00  to $ 499.00 for one year.