Application to Surrender

Name

FirstLast

Email

Phone Number

Age

Occupation

Desired Session Length

How did you discover me?

Be specific. "Online" is not an acceptable answer.

Personal Introduction

Describe yourself. List hobbies & interests, favorite bands/musicians, books, tv shows, movies. Describe your appearance. Do you like to travel? If so, tell me about a memorable trip. This is your main opportunity to catch my eye and present yourself as someone I might allow into my world.

Which submissive roles do you identify with?

Examples: submissive, bottom, slave, masochist, sissy, it/object, simply a fetishist.

Why do you wish to serve me?

There are no wrong answers.

Experience

Session Desires

Session Limits

List any activities you are not interested in exploring under any circumstances.

Physical Limitations

Include any relevant medical condition which may influence a session - Recent surgery, heart attack/stroke, high/low blood pressure/sugar, nerve damage/numbness/tingling, areas of pain, implants/pins/plates/pacemaker, asthma/respiratory conditions, glasses/contacts. Do you get lightheaded or have a history of fainting? Do you have trouble standing for periods of time or holding certain positions?

Additional Information

Use this space to ask any questions, address any concerns, or let me know anything you think I should know.

References

Name & website of another Domina you have seen within the past 2 years. Those without a reference will need to provide a photo ID or LinkedIn page through email. No exceptions.

By checking each box, I agree that:

After completing this form, send me an email letting me know you have submitted your application.

mistressalicelynch@protonmail.com

Rows	Light	Medium	Intense	Unsure	Not Interested
Corporal Punishment & Impact Play
Bondage
Humiliation
CBT
Nipple Torture
Posterior Play

Impact Play

Areas to focus on

Areas to avoid other than the obvious (kidneys, neck, etc.)

Impact Play Comments

Bondage

Bondage Comments

Humiliation

Favored Words/Names

Humiliation Comments

Cock & Ball Torture

CBT Comments

Nipple Torture

NT Comments

Posterior Play

Posterior Play Comments

Marks

Roleplay

Describe your roleplaying fantasies, if any.

Session Photography