Acknowledgement

~ Prebooking is highly encouraged in my base city and for tour dates as availability is

limited

~ Priority is given to those who complete all necessary screening

requirements & reservations with a deposit on file.

~ Prepay within 48hrs if using credit card. 5% Surcharge on all credit card payments.

~ Once your request is accepted you will receive a direct number to me.

~ You are welcome to email the information and questions to info@luxurielaren.com

I have read your website in its entirety and agree to the cancellation policy: *

I agree

About You

Full Name as Stated on ID: *

Age: *

Resident City and State: *

Ethnicity: *

Photo (optional):

Contact Information

Email (I will ALWAYS contact you by email unless otherwise stated): *

Phone Number (I will NEVER contact you by phone unless otherwise stated): *

Is it ok to leave a voicemail and/or send a text?: *

Yes, either is ok

Voicemail only

Text only

Neither

Preferred Method of Contact: *

Email

Phone

No Preference

Employment Screening

Occupation: *

Position/Title: *

Company Website:

Appointment Details

Preferred Date: * +

Preferred Time: *

*

Preferred Location: *

Duration:
Check out my specials for the connoisseur. *

Outcall Location (if applicable): Please give full address so I may put in my GPS :)

Name on Card:

Credit Card Type:

Credit Card Number:

CVV:

Expiration Date (mm/yy)

Zip Code:

* CC payments must be made 48 Hours prior to our scheduled meeting unless discussed otherwise.

** PREBOOK & PREPAY

*** 5% Surcharge on all credit card payments.

Online Screening Service

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

	Forum Usernames/Handles, etc
Date-Check	Forum Usernames/Handles, etc
Preferred 411	Forum Usernames/Handles, etc
Room Service 2000	Forum Usernames/Handles, etc
TER Username	Forum Usernames/Handles, etc
Other	Forum Usernames/Handles, etc

Reputable References

Please provide the information for at least two reputable companions you have spent time with. Companion /Reference #1:(include name/website/email/phone)
*

Please provide the information for at least two reputable companions you have spent time with. Companion /Reference #1:(include name/website/email/phone) *

Please verify that you understand the fact that I do not see anyone who is unable to provide references: *

I understand

SPECIAL REQUEST

Wine Preference: *

How did you hear about me?: *

Special Request(s):

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Riesling	Merlot
Chardonnay	Cabernet Sauvignon
Sauvignon Blanc	Pinot Noir
Pinot Gris	Zinfandel
Bottle Water*	Syrah