SCREENING FORM

Name*

First NameLast Name
Age*
Must Be 21+
Email*
example@example.com
Phone Number*
VoIP or text apps such as Google Voice will not be accepted.
City & State of Residence*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I found you on...*
I would like my inquiry answered via...*

Email OnlyText OnlyText or Email is OK
I will be using the following screening method:*

ID VerificationEmployment VerificationStudent Verification
Student Verification

Please provide your student ID and student .edu address below
Student Email*
example@example.edu
Please Provide a Copy of Your Student ID Here*

Cancelof
ID Verification

Please provide a copy of your unexpired government issued ID in the field below. Driver's licenses, state IDs card and passports are gladly accepted. For your privacy and safety, I recommend that you cover/black out information such as your license/ID number, SSN (if applicable) and your full address. Just your name, birthdate, city/state and picture need be visible.
Please Upload a Copy of Your ID Here*

Cancelof
Employment Verification

Please provide at least TWO of the following options.
Your Personal Listing On Your Company's Website
LinkedIn Profile
Must have a profile photo and at least 100+ connections
Direct Company Email
yourname@yourcompany.com
Direct Phone Number (include extension if applicable)
Your Work ID/Badge

Cancelof
Additional Screening Information (Optional)

While not mandatory, additional information may expedite and streamline the screening process if available. Examples of helpful supplemental information include links to social media (Facebook, Twitter, Instagram, etc), companion references or your P411 information. But again, this is completely optional.
0/1000
What Kind of Date Would You Like?*
Which City?*

CharlotteAshevilleGreenville SCKnoxville TN
Which City?*
City/State or Country
Which City?*
Your Place or Mine?*
Length*
When Would You Like to Meet?*

MonthDayYear
What Time?*

Hour Minutes

AM/PM Option
Is this date/time flexible?*

YesNo
Please Use This Space to List Alternate Dates and Times
All About You

Use this field to tell me more about you! I'd love to learn more about your favorite movies, books, music, drinks, hobbies, etc. You may also include any particular interests or pertinent health/mobility information (ex: a wheelchair accessible space will be required).
0/1000
DEPOSIT & CANCELLATION POLICIES *

I understand that a deposit is required, and I have read, understand and accept Gem DeMilo's deposit and cancellation policies.
Should be Empty:

Student Verification

ID Verification

Employment Verification

Additional Screening Information (Optional)

All About You