Application Form

Application Form

Name

Date of Birth

E-Mail Address

Height

Feet/Inches

Weight

Re-enter E-Mail

lbs.

Neck size

Inches

Scene Name
or Nickname

Men's

Shoe Size

Women's

Level of
Experience
(choose one)

Type of Domination
you desire
(choose all that apply)

How do you Identify
Yourself
(choose all that apply)

There are many sides to my personality, I enjoy so many aspects of
BDSM, and can exhibit many different styles of play.
Although, I reserve the right to play as I wish when I wish,
I would like to know what style you prefer, or would like to experience.
(choose all that apply)

If in a relationship, is your partner aware
of your pursuit of these BDSM activities?

Relationship Status

It does not matter to me
what it is. As with
everything else, this will
remain confidential

Yes

Is it acceptable for marks received in a
session to remain more than a few hours?

Yes

Do you have any of the following?
Select at Least
ONE of the following choices - explain in the box
below.
(choose all that apply)

List and explain any other medical,physical or emotional limitations
(Such as allergies, chronic conditions, traumas, phobias,past breaks, sports injuries etc.)
DO NOT LEAVE BLANK
(If none,write None)

List Your Limits
Specify if they are hard or soft limits
Don't waste time writing things I already stated I won't do.
DO NOT LEAVE BLANK (If none,write None)
DO NOT Write a scripted scene you wish me to enact!!
I WILL NOT Memorize scripted scenes.
I am NOT an Actress performing a role for your pleasure!!
I will ignore your request if you do.

Dates & Times You Would Like me to
Consider
BE SPECIFIC
about
DATES & TIME of Day
Monday - Saturday 10am -7pm
(I do not schedule new clients on Mondays or
Wednesdays )

If you are planning on
meeting with me in person
check one of the following
3 choices.

I live in the Capital Region

I travel to the Capital Region regularly

I am willing to travel to the Capital Region
for sessions

I HEREBY CERTIFY, BY CLICKING ON THE SUBMIT BUTTON BELOW,
I AM OVER 18 YEARS OF AGE,
& AWARE OF THE ADULT SEXUAL NATURE
OF THE INFORMATION THAT I AM REQUESTING.
I UNDERSTAND THAT SEXUAL ACTS ARE NOT PART OF THIS SERVICE AND
WILL NOT BE PERFORMED.
I ALSO CERTIFY THAT MY APPLICATION IS HONEST & TRUTHFUL &
SUBMITTED FREELY OF MY OWN DESIRE.

*Notice*
When making selections from drop down boxes,
you may make multiple selections, if allowed, by holding down
the Ctrl Key on your keyboard while clicking on the selection.