Who are you?

* Required Field

About You

Name: *
Age: *
Traveler to this area:
City: *
Ethnicity:
Occupation: *
Company: *
Photo: *
Any Questions?

Contact Information

Email: *
Phone: *
Accept SMS/Text:
Best Times to call: *

Appointment Details

Preferred Dates/Times: *
Preferred Location: *
Preferred Length: *
Outcall Location:
Traveler to this Area:
Any Likes or Dislikes:

Companion References

Names and contact info of providers you've seen before..
How did you hear about me? *
P411 Username:
TER Username:
Eccie Username:

No References? (Other Verification)

Facebook Link:
LinkedIn Profile:
Instagram Profile:
Business Website / Other:

The screening process is for my security and your comfort that I am a legitimate business who serves only credible clients. It takes 24-48hrs. 

What I require from you: Name, contact information and current references or okays from P411 or TER independent companions. If you do not have references, there are other screening options we can discuss. Please fill out the form the best you can & mention during booking. The information filled out will stay secured and completely confidential.