1. Name _____________________________________
2. Gender (circle one) M / F
(Note: if you did not circle the “F”, you’re application will be forwarded to Russell Johnson of Columbia, MD)
3. Local address ________________________________________
(please include directions and leave the door open)
4. Phone number _________________________________________
(keep in mind, he knows that rejection hotline number in all area codes)
5. How often do you see a therapist (PTs do not count) on an average week?
A. 4 or more
B. 2 or 3
D. None, but I should
(If none of the above apply to you AND you are currently single, your application will be forwarded to Bill Wilcox)
6. How do you know Dustin?
A. I work with him.
B. Through a friend
C. Through facebook
D. I don’t know Dustin but a friend forwarded this to me and I’m desperate enough to try anything.
7. What is your ideal Valentines Day date?
A. A train ride up to New York to see Rent, skating in Central Park, dinner at the Four Seasons and a full body massage by the fire in a 5 star hotel.
B. Dinner at the Olive Garden, a couple drinks at a local martini bar, and out to a drive-in movie for a viewing of Hope Floats while snuggling with each other.
C. McDonalds for a few burgers and back to my place to watch reruns of King of the Hill with a box of wine.
D. Smack Ramen and Natty Light while checking out internet porn together.
8. What are you looking to get out of this Valentine’s Date Application?
A. To spend an evening with a guy who I don’t mind too much.
B. I want to get married soon because my eggs are rotting.
C. Honestly anything, I haven’t been allowed out in 5 years.
D. I figure if I go out with Dustin, I have a better chance of hooking up with Bill.
9. What did you do last Valentines Day?
A. Had a romantic evening with my boyfriend/fiancee/husband.
B. Went out with the girls to protest the Hallmark holiday.
C. Hooked up with some guy I don’t know because I’m very insecure.
D. Fell asleep on the couch watching Duck Tales.
10. Lastly, the thought of kissing Dustin makes you…
A. Tingle inside
B. Throw up
C. Need to pee
D. Pity others who have