Registration Form

We look forward to receiving your registration form.

Please note that your registration form will NOT be complete until you have emailed us photos AND answered ALL the questions below. 

For your photo submission, please send at least 2 head shots and 2 full body shots that have been taken WITHIN the past 3 months.

You DO NOT have to have professional shots taken.  

Please submit photos to:


Name *
Phone *
Today's Date *
Today's Date
Mutual Friend? (Who?) Met Samantha or one of her staff? (When and where?) Press? Internet Search? Other?
Which city and where specifically in that city?
Where did you go? What did you major in?
Do you have kids? Do you want kids? Will you date someone with kids? Will you date someone with kids and doesn't want more?
(Height, weight, hair color, eye color, dressing style. Anything you want to share)
You can use adjectives or just describe yourself and/or how your friends would describe you.
(Age, height, personality, background. Anything you want to share)
(If you do not have one, put N/A)
(If you do not have one, put N/A)
Network membership is subject to verification of the information provided herein, determination of the suitability of the service for the applicant as well as the occurrence of a face-to-face interview. By filling out this form, you are agreeing to the confidentiality of this process as well as agreeing not to disclose any information of any sort to any other dating/matchmaking service and/or to any media source of any kind without express written consent from Samantha’s Table, LLC.
Please submit your photos to