Contact / Appointment Form |
Any false information given after an appointment
is confirmed, could result in the loss of your deposit, and jeopardize any chance
of us ever getting together. |
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*All Fields marked
in Bold are Required |
| Where
would you like to meet me? |
New York
Las Vegas
St Louis
Other, please specify: |
| Date
of Appointment | ,
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| Time
of Appointment |
|
| How
long will our appointment be |
Please
Check your choice.
1 hr. $800 (VIP Only)
2 hr. $1200
3 hr. $1600
4 hr. $2000
12 hr. $4500
24 hr. $7000
3 days $14,000
7 days $25,000 |
| How
will you pay the donation? |
Cash
Cashiers Check
Money Order
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Location |
Your Residence
Hotel
Other, please specify: |
| Name of Location |
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| Address |
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| City |
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| State |
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Personal Information
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| For
security purposes, I will ask you for valid identification, such as a passport
or a drivers license. If in a hotel, you must be registered in your name. I am
extremely discrete and always keep personal information confidential. |
| First Name |
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| Last Name |
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| Age |
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| Company |
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| Occupation |
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| City |
|
| State |
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Contact Information
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| Phone
(direct line) |
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| Email |
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| Work
(company main #, no direct lines) |
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| Mobile |
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* Note: Please
let me know if you are a TER member (for efficiency)
Enter your TER username
|
Were
you referred to me?
yes, no
If yes, what is the
name of the client or agency that referred you?
If no, how did you find out about my website?
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Additional Comments |
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