First name: Middle Initial: Last Name:

City: State: Country:
Please provide a brief description of yourself:

E-mail:
Home Phone:
Work Phone:
Cellular Phone:
Pager:
Fax:
Other:

Date(s) you would like to secure a consultation:

Type of consultation you are interested in:
Hourly Evening Travel
Describe the detailed scenario for your consultation: Please type the name of the girls you would like to meet below.
First Choice:

Second Choice:

Third Choice:

Describe the type of lady that most appeals to you:

Additional Comments:

If you would like an all inclusive fee please check the appropriate box
if any of the following apply to your request:

	Airfare
	Hotel
	Limousine
	VacationPackage

Select the all inclusive fee range that you are most comfortable
with for the appointment you have requested:
Choose One $6,000-$8,000 $8,000-$12,000 $12,000-$15,000 $15,000-$25,000

Were you referred to us by an existing client?
No, I was not referred Yes, I was referred
If YES, what is the name of the client that referred you?

If NO, how did you find our website?

Special instructions for the proper handling of your request:

Additional Comments: