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To Be A Re-Born Virgin



Thank you for applying for Re-Born Virgin status! This is a simple application so please be honest. We will get back to you with our answer soon. Make sure you answer all questions. If you would like to start over, there is a "reset" button at the bottom. Otherwise, when you're done, just hit "Submit"!


Name:
Age:
E-Mail Address:


PLEASE ANSWER AS APPROPRIATE:

My last sexual experience was:

Yesterday Last Week Last Month 2-6 Months Ago 7-11 Months Ago Longer Than I Can Remember Other:



My Last Sexual Experience Took Place:

In The Bedroom In The Kitchen In The Shower/Bathtub On The Floor On A Couch At A Party In A Swimming Pool/Jacuzzi In The Neighbors Back Yard Swimming Pool With The Pizza Guy In A Boat In A Gazebo In France Other:


My Last Sexual Experience Was With:

My Husband/Wife; My Ex-Husband/Wife; My Ex-Husbands Brother; My Ex-Husbands Sister; The Pizza Boy; The Milkman; Meter Reader; Telephone Repairman; Septic Tank Cleaner; Other

My reasons for wanting to be a ReBorn Virgin (in 50 words or less)



Hobbies/Interests:

Sports; Cooking; Gambling; Arts & Crafts; Reading; Travel; Photography; Line/Square Dancing; Poisoning Pigeons in the park; Harassment Of Ex-Spouse/Ex-Spouse's New Spouse; Nose Picking; Other


Pets:
Cat; Dog; Fish; Rodent; Furby; Spouse/Significant Other; Other


Can we contact your last known sexual partner?
Yes; No

If Yes, Please Fill Out Info Below:
Name:

Phone Number:
Email Address:



Would You Be Willing To Take A Lie Detector Test?
Yes; No


What Name/Word Do You Refer To Your Last Shameful Experience:

.......... Making Love
.......... Having Sex
.......... Screwing
.......... Doing The Dirty Deed
.......... Doing Nasties
.......... Humping
.......... Fornicating
.......... Making Whoopy
.......... So Long Ago I Don’t Remember
.......... Other


Do You Suffer From Any Of The Following:

.......... Depression
.......... Hallucinations
.......... Phobias
.......... Snoring
.......... Insomnia
.......... Obsessive/Compulsive Behavior
.......... Hiccups
.......... Constipation/Diarrea
.......... Body Odor
.......... Bad Judgment
.......... Heavy Panting
.......... Incontinence
.......... Uncontrollable Laughing
.......... Road Rage
.......... Flatulence
.......... Fetishes (list below)

.......... Other


If You Are Approved For Re-Born Virgin Status Will You:

1. Wear Your Badge Proudly
Yes; No

2. Frame And Hang Your “Certificate Of Approval”
Yes; No
3. Use Your Membership Card At All Accepting Establishments
Yes; No
4. Honor All of the Re-Born Virgin Guidelines & Rules
Yes; No
5. Promise To Uphold The Re-Born Virgin’s Pledge Of Allegiance
Yes; No
6. Abstain From Shameful Fornication (Even If He’s A Hunk or She's Gorgeous)
Yes; No
(Answers don't HAVE to be yes, you know!)



Thank you for applying for “Re-Born Virgin Status” Your application will be evaluated by Nikki and Veronica within One to Two weeks of receipt. You will be notified of acceptance within a week of verification. Good Luck and Thank You for your interest in joining this fine organization.




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