Contact Information:

Personal Information about you.

This is for contact and verification purposes only! It will not be saved , used or sold to a third party!

Come and experience a new culture. The culture of the Kama Sutra from an experienced Exotic East Indian Godess.

Full Name:

First *

Middle *

Last *

E-mail: *

Your Address

Street Address *

12345 anywhere

City *

State: *

Zip *

Other Address if applicable:

Street Address

City

State: *

Zip

Home Phone or cell# and plaese state which one? *

Extenstion:

Who to ask for only if you want me to call back? Plese answer only if you want a call back!

Work Verification:

Business name: *

Phone#:

Address: *

City: *

State: *

Business Website:

Person to contact for verification: *

Their E-mail Address:

References

Name:

E-mail:

Phone#

How will she remember you?

Name:

E-mail:

Phone#:

How she will remember you?

Appointment date and time preferrences.....

What date would you like your appointment? *

What time would you like the appointment? *

How long of a session are you wanting? *

An Alternate date if not available? *

Alternate Time? *

If no references and you are a newbie, please state so here. Type in "NEWBIE"

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EAST INDIAN BEAUTY NINA