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I Have Seen You Before
First Name:
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Email Address:
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Phone Number:
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Preferred Date:
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Preferred Time:
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AM
PM
Preferred Location:
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Incall
Outcall *1.5 minimum reservation
Duration:
Check out my specials for the connoisseur.
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1 Hr
1.5 Hr
2 Hr
3 Hr
4 Hr
8 Hr
12 Hr
24 Hr
48 Hr Excursion
LuXurie Weekend
LuXurie Vacation
LuXurie Muse for the Week
Non-Exclusive for the Month
Exclusive for the Month
Outcall Location (if applicable) so I can put in my GPS:)
Name on Card:
Credit Card Type:
Visa
MasterCard
American Express
Discover
Credit Card Number:
Expiration Date (mm/yy):
Zip Code:
CVV:
** 5% Surcharge on ALL CC Payments **
Special Request
Wine Preference:
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Riesling
Merlot
Chardonnay
Cabernet Sauvignon
Sauvignon Blanc
Pinot Noir
Pinot Gris
Zinfandel
Bottled Water*
Syrah
Dress or Other Request:
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