My Name:
My Email:
Member#
My Introduction:
Member#

Please tell us how your date went?

In what ways could we improve your next introduction?

On a scale of 1-10 (1 being the lowest and 10 the highest), how do you think your overall date went?	1 2 3 4 5 6 7 8 9 10
Do you think you would like to see him/her again?	yes no maybe

Comments:

The above information is to help us fine-tune your membership. Please mail, fax, or e-mail your feedback to us as soon as possible, so we are able to update your personal file. If you have any further questions regarding your membership you may call us at (804) 967-9911.  The best time to reach us is Monday through Thursday from 5 - 9 p.m.