Couples Form

FORM TO COMPLETE

Information is confidential.

Please fill all blanks.

Woman's name? First name Name

Man's name? Firs tname Nname

E-Mail?

What is your civil statement? Husband & wife Living together Friends

Woman's birthday? 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 January February March April May June July August September October November December Man's birthday? 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 January February March April May June July August September October November December

Address (number, street & appartment)?

City? Province?

Postal Code? - Country?

Telephone? 450 514 613 819 Other - Home phone

Telephone? 450 514 613 819 Autre - Office phone

Cellular phone? 450 514 613 819 Autre - Cellular

How did you know about us?

Payment mode : CheckSend to : AEQSA 3848, Taschereau, #51569, Greenfield Park, Quebec J4V 3N8

How may we communicate with you? All conversations are confidentials. Check one or more. By E-Mail By civic addressUnidentified enveloppes. By my home phone May we leave a message? Yes No By my office phoneMay we leave a message? Yes No By my cell phoneMay we leave a message? Yes No

Comments :

All blanks must be filled. Send your request to AEQSA by clicking this button. If we received your request, a confirmation page will be seen.

---