Contact

Employment information is needed for new clientele that do not have solid provider references. Please fill out the form below, so I am able to verify you as quickly and discreetly as possible!

Your Information

First Name (required) *
Last Name (required) *
Age (required)
Personal Contact # (required) *
City For Our Meeting (required) *
Your Private/Secure Email (required) *

Employment Information

Occupation/Former Occupation if Retired
Employer Name
Employer Phone # Discreetly Used To Verify Employment
Employer Website

Provider Reference #1

Provider Name
Provider Email
Provider Website

Provider Reference #2

Provider Name
Provider Email
Provider Website

P411 Verification

Please Enter Your P411 ID #

Appointment Details

Appointment Date (required) *
Appointment Time HHMMAM/PM
Appointment Length
Incall or Outcall
IncallOutcall
Additional Information
Please add any extra information that will help complete the screening process or tasteful special requests for our meeting.

Verification

Please enter any two digits *Example: 12
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