Please consider: You need to choose at least 5 ladies.

• Lady #1

  ID:*First name:

• Lady #2

  ID:*First name:

• Lady #3

  ID:*First name:

• Lady #4

  ID:*First name:

• Lady #5

  ID:*First name:

• Lady #6

  ID:First name:

• Lady #7

  ID:First name:

• Lady #8

  ID:First name:

• Lady #9

  ID:First name:

• Lady #10

  ID:First name:

First name:*

Surname:*

Street:

Post code:

Place of residence:

Country:

Telephone number:*

When can we best contact you?

(e.g. in the evening or at the weekend)

Mobile phone:

E-Mail address:*

Nationality:

Date of birth:*
01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 01 02 03 04 05 06 07 08 09 10 11 12 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 1984 1985 1986 1987 1988 1989 1990 1991 1992

Height:*
 cm

Weight:*
 kg

Profession:*

Other languages:

Smoker:*
NoYes

Marital status:*
single
divorced
widower
living separately (only if already petitioned for divorce)

Children:*
Yes, aged: living with you:
No

Do you want to have children:*
Yes
No
it depends on the partner

Age:*
 up to years

Height:
 up to meters

May the lady have children?*
Yes, one
Yes
No

Remarks:

more about you or your future partner…

Your photo:

Photo #2:

I will send my photos per post to::
MA-Polonia, ul.Krowoderska 61a/9, 31-158 Krakow