Over40s Application Form | Over 40s Professionals Dating Agency

If you would like further information about our organisation, please fill out the following form. Alternatively you can telephone us on : 0207 930 5555

Title: *

First Names: *

Surname: *

Name we can call you on the telephone: *

Address1: *

Address2:

Town/City: *

Post Code: *

Telephone numbers. Put an * against the numbers you would want us to use

Home Tel no: *

Work tel no: *

Mobile: *

Email we can use: *

Age: *

DOB: *

Occupation: *

Salary scale: *

Height: *

Weight: *

Are there any facts that you should declare to us that would influence whether we would accept your membership?: *

This is an application to the membership controller for a two year Social Membership to Executive Parties at £125 we will reply within 5 days. If you are accepted we will telephone you for the £125 payment by credit or debit card, alternatively you may choose to send a cheque.

When attending your first social event you will be required to produce a passport or driving licence to prove your identity plus one of the following to prove your address: a bank/ credit card statement a gas/electricity/telephone.

I have read the rules and conditions of membership and apply for membership on the clear understanding that these details are to the best of my knowledge true. I am not married, engaged to be married or living with, or in a long term relationship with anyone.

If separated when was the last time you either lived together/had sexual relations with your ex partner?: *

Type your name and date here as acceptance: *