Please fill out the information below and email it back to me for screening and verification.
Full Legal Name:
Birth date:
City and Sate you reside:
Email address:
Phone Number:
References (Names/contact information of other providers you have seen or employment information such as a link to you on your company web site to aid in screening):
If referred by another, who?:
How did you find me?:
P411 Name:
What date would you like to meet:
What time would you like to meet:
How much time will be spending together:
Where will we be meeting:
Special requests (HD Experience rates will apply for all clothing/lingerie requests, toys, role play, and greek):