Reservations

12/20/09
 

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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.

*All Fields marked in Bold are Required
 
Where would you like to meet?

  St. Louis

  Kansas City

  Chicago

  Las Vegas

  New Orleans

  Fort Lauderdale
Date of Appointment:

,

Time of Appointment:

How Long Will Our Appointment Be:

20 minute meet & greet (public location)

   1 hour  $800

  2 hours  $1100

  3 hours  $1300

  4 hours  $1500

  12 hours $2000

  24 hours $ 2500

**All appointments are contingent on two reference checks.
How Will You Pay the Donation?

Location?

  Hotel    

  Other.  Please specify below.

Name of Location

Street Address

Street Address

City

State

Zip

 

Personal Information
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

Last Name

Age

Company

Occupation

City

State

 

Contact Information
Phone (direct line)

Email

Company main # (no direct lines)

Mobile

References
I do require two references that check out before we meet.  Please understand that this is purely as a safety precaution.

Reference #1  Name:    Email:

Ph:   Weblink:

 

Reference #2  Name: Email:

Ph:    Weblink:

* Note:

Please let me know if you are a member of one of the following:

TER member please enter your username and email me an appointment request through their site.

Preferred411 member please enter your username and email me an appointment request through their site.

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?

Additional Comments: 

 


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This site was last updated 09/08/09