Fill out this from to see if you qualify for a date with Jay.

First Name *

Last Name (Optional)

Phone *

How old are you? *

How tall are you? *

How many tattoos do you have? *

How many kids do you have? *

Have you always been a woman? *

Yes - I have always been a woman!

No - I might be a bit confused...

Upload a recent photo of yourself (Optional)

Upload a photo

PNG, JPEG or JPG

Choose the option you'd prefer for a first date : *

When would you be available for our date? *

Do you have anything you'd like to share with me before our date? (Optional)

I understand that this form is meant as a joke and i find it somewhat funny enough to still go forward with the date.