PAKSEANA MATRIMONIAL SERVICE

Registration Form

3251 Pebblewood Road, Mississauga, ON. L5N6P4

Phone: (905) 824 0917 Email:

1 / Name
2 / Phone: / Home / Cell:
3 / Address:
4 / Email:
5 / Date and place of Birth:
6 / Height / Weight
7 / Complexion / Very Fair / Fair / Wheat / Dark
8 / Father's Name:
9 / Mother's Name:
10 / Number of siblings and their ages:
11 / Citizenship:
12 / Country of Residence:
13 / Current Status in North America: Citizen / Landed Immigrant / Student / Refugee / Other
14 / Mother Tongue
15 / Other Languages Spoken
16 / Marital Status: / Single / Divorced / Widowed / Legally separated
17 / Number of children from Previous Marriage(s) with ages
18 / Legal Responsibility (if any) / Custody / Living with you / Visitation
19 / Personal Characteristics / Friendly / Quiet / Social / Sports / Other / Smoker / Non-Smoker
20 / Consume Alcohol / Drugs / Yes / No
21 / General Health
22 / Disability (if any)
23 / Religious Affiliation / Sunni / Shia / Qadiani / Ismaili / Other
24 / Fiqah / Hanafi / Shafi / Hanbali / Maliki / Other
25 / Education: / Less than High School / High School / College Diploma / University Degree / Masters / Other
26 / Major Subject:
27 / Occupation:
28 / Place of Employment
29 / Annual Income / Under 10,000 / 20 - 30 K / 30 -40 K / 40-50 K / Over 50 K / Over 70 K / More
30 / Criminal Record / Yes / No / If yes, provide detail:
31 / Is there anything you would like your potential spouse to know about you?
32 / Please describe your preferred match - What are you looking for in your potential spouse?
33 / Three References: One from family and two from outside your family:
1
2
3
For Official Use only:
File #
Date of Receipt of Registration form:
Received By:
Reviewed By:
Fees Received
Comments

·  Please check off (√) the applicable and appropriate box.

·  Use an extra sheet of paper if you need more space for any information.

·  Mail in the completed form to the above address.