Appointment Request Form

Potential Sub Application
Name*
Age*
Username on Instagram/Twitter/Fetlife *
E-mail*
Where do you live? (City, State)*
If you do not live in Los Angeles are you willing to pay for my travel?*

YesNoI live in LAOther
Phone Number

Area CodePhone Number
Best way to contact you?*
What days work best for you?*

MondayTuesdayWednesdayThursdayFridaySaturday
What time works best for you?*

MorningAfternoonEvening
How much can you pay? How often (daily,weekly,monthly, per session)?*
Your form will automatically be rejected if you enter 0 or zero.
Why do you want to worship me?*
What services are you interested in (kinks, fetishes, scenes)?*
Hard Limits/Soft Limits*
Please verify that you are human*
Should be Empty:

Potential Sub Application