Approved ( ) Yes  ( ) No		Tested For Aids? ( ) Yes  ( ) No
Denied ( ) Yes  ( ) No		Physician_________________

• Name____________________________
• Address_______________________________
• Age_____
• Phone____________
• Social Security#______________________________
• Hair Color________
  Real? ( ) Yes  ( ) No
• Eye Color__________
  Real? ( ) Yes  ( ) No
• Dentures?
  ( ) Yes  ( ) No
• Height_________
• Weight_________
• Waist Size_______
• Marital Status:
  ( ) Married
  ( ) Single
  ( ) Divorced
  ( ) Attached
  ( ) Cheating
  ( ) Other
• Chest or Bra Size_________________
  Are they real? ( ) Yes  ( ) No
• Are your nipples:
  ( ) Small
  ( ) Medium
  ( ) Large
  ( ) Pink
  ( ) Peach-colored
  ( ) Dark
• Do you like them:
  ( ) Sucked
  ( ) Chewed
  ( ) Kissed
  ( ) Caressed
  ( ) Squeezed
  ( ) None of the above
  ( ) Other_________
• Can you stay out late?
  ( ) Yes  ( ) No
  How Late?____
  All Night____
  Several Days?__
• Do you like to be screwed? ( ) Yes  ( ) No
  How often?__________
• Do you take it in the ass?
  ( ) Yes  ( )No
• Do you like giving Oral Sex?
  ( ) Yes  ( ) No
  Receiving?
  ( ) Yes  ( ) No
• Penis or Pussy Size:
  ( ) Microscopic
  ( ) Small
  ( ) Medium
  ( ) Large
  ( ) Extra Large
  ( ) Does it matter?

• Are you shaved?
  ( ) Yes  ( ) No
• While Screwing do you:
  ( ) Faint
  ( ) Fart
  ( ) Cry
  ( ) Moan
  ( ) Hum
  ( ) Scream
  ( ) Whistle
  ( ) Yodel
  ( ) Scratch
  ( ) All of the above
  ( ) Just lay there
  ( ) Other__________________________
• When you come, Do you:
  ( ) Wiggle
  ( ) Wobble
  ( ) Twist
  ( ) Jerk
  ( ) Scream
  ( ) Moan
  ( ) Cry
  ( ) Other?________________________________________

• What kind of screw do you like?
  ( ) Fast
  ( ) Slow
  ( ) Super Fast
  ( ) All night
  How many times_______
  Comments_________________________________________

• How long do you screw at one interval?_________________________________
• Do you want to screw now?
  ( ) Yes  ( ) No
• If you have screwed before, Give 2 References (Not Immediate Family)
• Name__________________________
  Address_______________________
  Phone___________
• Name__________________________
  Address_______________________
  Phone___________
• If the Application is favorable, what are your charges? If any?
For one night____________
One Hour___________
Muff Burger Special or Blow Job______________
• What credit card will you accept?
  ( ) Master Card
  ( ) Visa
  ( ) Sears
  ( ) JC Pennys
  ( ) Shell
  ( ) American Express
  ( ) Citicorp

• Do you have any pictures to attach?
  ( ) Yes  ( ) No

I verify the Above Information is the Truth, So Help me God!!

___________________________________
Signature

___________________________________
Date