laineoftexas@gmail.com

 

 

Already a member: please email me through your account.

 

Prefer not to join?  No worries, just provide me with the information below. Incomplete forms will be ignored and deleted.

 

Please be reassured, ALL of your information is destroyed after it is verified. With the exceptions of, and only with your permission, the email address (used only to notify you of my travel dates) and the phone number (I like to know who is calling if and when this occurs)

 

You will only be emailed travel dates for 3 months after our 1st visit, after which, unless otherwise instructed by you, will be removed from my mailing list.

 

New Appointment Request
First and Last Name, as on Driver's License: *
State your Driver's License is Issued by: *
Last Four Digits of Driver's License: *
Please use SSC if above doesn't apply:
Email *
Phone *	### - ### - ####
Is permission granted? *	YES NO
Date of Birth: *
Your Ethnicity: *
City and State you live in: *
Company You are Employed By:
Main Number of your Employer and extention:
Your cell phone number:
Is permission granted?	YES NO
What city are you wanting to visit in? *
Date Time	1 2 3 4 5 6 7 8 9 10 11 12 MM / 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 DD / 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 YYYY 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 HH : 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 MM AM PM AM/PM
Reqested Length of Visit:
2 Providers you've visited within the last 6 months and the date you visited: if you cannot provide 2 provider refs. please include a photo of yourself.
Providers' website URL, email & phone numbers:
I do not take references from ladies who only have a phone number as a means of contact. I must be able to contact them via email,pm or through their website
Questions or Comments: