Appointment Request
Please provide your name and contact information below.
First Name :
*
Last Name :
Email :
*
Resident City and State :
Physical Description, Age, Race, Height, Weight :
Contact Number :
Is it ok to leave a voicemail or send an email?
Yes, either is fine
Voicemail only
email only
Neither
Preferred Method of Contact :
Email
Phone
No Preference
Online Screening Service
If you are a member of one of the following screening services, please provide the necessary details I need to verify you.
Preferred 411 :
Companion References
Please provide the name, email, and website address for at least two reputable companions you have spent time with
Reference #1 :
Reference #2 :
Employment Information
Please provide your employment information below
Company Name :
Position/Title :
Company Website :
Company Phone Number :
Your Direct Line or Extension :
Phone etiquette or cover to use when calling :
Appointment Details
Please outline your appointment preferences below.
Requested Date :
Preferred Time :
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01
02
03
04
05
06
07
08
09
10
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12
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:
00
05
10
15
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25
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55
Duration :
1 hrs
1.5 hrs
2 hrs
3 hrs
4 hrs
5 hrs
6 hrs
Overnight (12 hrs)
Full Day (24 hrs)
Weekend (48 hrs)
Other (Describe in comments )
Location Address :
Miscellaneous Information
How did you find me?
Is there anything else you would like to tell me?