Please read each question carefully. Take your time to think about yourself and fill out this form. This may change your life. Some questions are personal, however, please do not be offended.
Spotlight Advertising Fee - $50.00 /month. You need to send at least 3 regular pictures to Pacific Relations. Spotlight Advertising limits 5 people every month. If there are more than 5 people, your ad will be posted the following month.
Your Contact Information 　 First name Last name Date of Birth / Age January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 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 I am years old. Address - Street, Apt# City State/Provice/Prefecture Zip/Postal Code Country Phone (Home or Cell) Phone (work) E-mail address (Make sure your e-mail address is correct. This is the primary contact source) *E-mail address (Please check if it is correct) How did you find Pacific Relations? Active Singles Life Hiragana Times Links Seattle Weekly Search Engine Soy Source Through Friend Tokyo Notice Board Other 　 　 Your Personal Data 　 What is your nationality? What is your ethnic background? Caucasian Hispanic African American Asian American Indian What's your height? -- 3 feet 4 feet 5 feet 6 feet 7 feet 0 inches 1 inch 2 inches 3 inches 4 inches 5 inches 6 inches 7 inches 8 inches 9 inches 10 inches 11 inches What's your weight? Lb. Your eye color / Hair color Blue Green Hazel Brown Gray / Blonde Dark Blonde Light Brown Brown Dark Brown Black What is your education? High School Graduate Trade/Technical School Certificate Some College (2 years of classes) College Graduate (Bachelors degree) Graduate School (Masters degree) Ph.D. What is your marital status? Single (Never married) Married but separated Divorced Widowed Do you have any children? Yes No If "Yes", Please state the condition. ( Ex: son is 2, and daughter is 4, both living with their mother) What is your religion? Christian Catholic Jewish Muslim Buddhist Other Not Religious What is your occupation and job title? What is your approximate annual Income? less than $20,000 $20,000-34,999 $35,000-49,999 $50,000-74,999 $75,000-99,999 $100,000-149,999 $150,000-199,999 $200,000 or more Do you speak Japanese? Cannot speak Japanese Survival level (Know 10 basic phrases) Fair (Took some Japanese classes) Good (Llived and worked in Japan for about 1 year) Very good (Lived and worked in Japan more than 2 years) Fluent How often do you smoke? Don't smoke Smoke occasionally Smoke 1 pack a day Smoke more than 1 pack a day Want to quit How often do you drink? Don't drink Drink a little Social Drinker Drink every day Alcoholic What are your hobbies and interest? 　 　 Do you want children in future? Yes No Undecided Are you interested in living overseas? (Are you willing to move to your partner's country?) Very Interested (2 years or more) Interested (2 years or less) Slightly Interested (Travel often) Very Slightly Interested (Travel sometimes) Not Interested *Do you want us to put your profile on "Spotlight" page ? (This is optional. In order to put your profile on "Spotlight", you need to submit at least 3 pictures, and send your text message by a separate e-mail.) Yes No 　 　 My Request Match 　 What's the age range of your Match? Between:  18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99  and  18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 What's the education level of your Match? High School Graduate Trade/Technical School Certificate Some College (2 years of classes) College Graduate (Bachelors degree) Graduate School (Masters degree) Ph.D. or higher What's the marital status of your Match? (Select as many as you like) No Preference Single (never married) Divorced Widowed What's the minimum annual income for your Match? No Preference At least $20,000 At least $35,000 At least $50,000 At least $75,000 At least $100,000 Does your Match smoke? No Preference Doesn't Smoke Smokes Occasionally Smokes 1 pack a day Smokes more than 1 pack a day Does your Match drink? No Preference Doesn't Drink Drinks a little Social drinker Drinks every day Do you have any messages for your future spouse? 　 　 Important Questions 　 Are you physically and mentally healthy enough to conduct a normal marriage life? Yes No Do you have any sexual transmitted diseases (Examples are AIDS, Herpes, etc...)? Yes No Within the past 5 years, have you been arrested, entered a plea of guilty or been convicted of a misdemeanor or felony offense against criminal, civil, military law, or been released from a prison, or detention facility, or are you now under charges for any offense against the law? Yes No 　 　 Membership Policy 　 Please Select Membership Listing Trial 3 months 6 months 1 year Please read the following before you submit the form. (1) You must be single and marriage-minded. (2) You must be 21 years old or older. (3) You must respect the privacy of the other Pacific Relations clients. (4) You must not take illegal drugs. (5) You must not be involved in any illegal activities. (6) You cannot have any criminal record for the last 5 years. (7) All clients affirm that they are in sound physical and mental health and are able to conduct a normal social and marital life. (8) All clients are required to register a personal profile with at least one good photograph. (9) Pacific Relations reserves the right to edit any personal profile to protect clients' privacy and provide the most current information of our clients to our other clients. (10) All documents submitted to Pacific Relations shall contain nothing but the truth and all photographs submitted to Pacific Relations shall be accurate representations of the client. (11) Pacific Relations may refuse service or terminate service to people that we determine are displaying an uncooperative or hostile attitude. (12) Pacific Relations pledges to take reasonable care in all its duties, and all clients agree to hold Pacific Relations harmless for inadvertent errors by Pacific Relations and misdeeds by other clients. (13) In the unlikely event that legal disputes of any kind should arise between Pacific Relations and a client or clients, all parties agree to submit the dispute to a mutually agreeable, neutral third party for mediation and settlement. (14) All documents and photographs submitted to Pacific Relations become the property of Pacific Relations. (15) Pacific Relations will distribute the clients, profiles & photos to potentially interested individuals of the opposite sex. (16) All clients grant Pacific Relations rights to distribute their profiles and photos. (17) All clients agree that all the profiles and photos they receive may not be copied, redistributed or resold. (18) Pacific Relations guarantees to distribute the profiles and photos for a minimum of one year unless requested by the client to stop. (19) Fees are non-refundable. (20) Pacific Relations will do what it can to help clients find compatible mates, but Pacific Relations cannot guarantee results. (21) Pacific Relations can assume no liability for what happens between clients. The individual clients themselves are responsible for their own behavior. (22) Clients shall notify Pacific Relations upon becoming engaged or married so that Pacific Relations can cease distributing their profiles and photos. I swear that my contact information and my personal data given to Pacific Relations are all true and I comply with Pacific Relations Policy on Introductions. I understand Pacific Relations do not and will not guarantee to find my future partner. I agree I disagree