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Thank you for your interest in booking an engagement with me. Please fill out the following screening information about yourself. If you don't receive a response back from me within 24hrs it's because I'm not interested in seeing you for the following reasons:

I won't see any new clients without two verified provider references listed and she must be a reputable provider in your community.

I won't see clients under the age of 35yrs.

Occupation and phone info are optional to fill on form.


 
 Personal Information
Name
Email
Phone Number
Home City & State
Age
Occupation

 Reservation Details
Date Desired
Time
:
Incall/Outcall
Length
In what city would you like to meet?

 Provider Reference
PROVIDER REFERENCE 1
 Website Url
 Email Address

PROVIDER REFERENCE 2
 Website Url
 Email Address

 Verification Service Membership
 Service Name
 UserName or ID

 Additional Details


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