Screening

Appointment Request

Please provide your name and contact information below.

Full, Legal First and Last Name

First Name

Last Name

Email Address

Contact Number

Legitimate numbers only (i.e. no Google Voice or "burner" phone numbers)

Country

(###)

###

####

Resident City and State

Age

Online Screening Service

If you are a member of one of the following screening services, please provide the necessary details I need to verify you.

TER ID

Preferred 411

Companion References

Please provide the name, email, and website address of at least two reputable companions you have spent time with.

Reference #1

Reference #2

Appointment Details

Please outline your appointment preferences below.

Requested Date

YYYY

Preferred Time

Hour

Minute

Second

Duration

Miscellaneous Information

How did you find me? (e.g. Eros, TER, Slixa, etc)

Brief physical description

What do you find attractive in a companion?

Please tell me a little bit about yourself

Anything else you want to tell me?