Make a Reservation: All boxes must be filled out or the form will not submit.

Make a Reservation: All boxes must be filled out or the form will not submit.

I only ask for your personal information since my safety is of the utmost importance and it is required for the screening process. For your comfort and security the appointment request form is an SSL encrypted page that ensures secure transmission of your information. The information comes directly to me, Please be concise in your responses and be assured that all information will be held in the strictest of confidence. I am an extremely discreet person and expect the same of you. A uniqueness about myself as a Courtesan provider is that I too reveal private information and I use my real identity with you as well. Once all information and your appointment has been processed and confirmed I will require a 40% non-refundable deposit.
What is your legal name? *
What is your age? My time is reserved for gentlemen over 30. *
What is your occupation title? *
What company do you work for? *
Please leave general work number. Switchboard with extension. *
What is your best contact number for me to use? *
What is your email address *
What city do you reside in? *
What city would you like to meet in? *
At what address would you like to meet? *
What is the date of requested appointment? *
What time would you like to meet? *
How may days would you like to spend together? *
Reference: Please list an Independent Escort you saw in the past *
Please list your Reference Website or her email address. *
How did you find me? Example: Eros guide/CityVibe *
All of my travel fees are included in my rates. ~ Might you have a private Jet or for any other reason would you be interested in paying for my travel arrangements? (This is strictly optional.) *	Yes No
Is there anything else you would like to add to your request? *