Approved ( ) Yes ( ) No
Denied ( ) Yes ( ) No
Tested For Aids? ( ) Yes ( ) No
Tested For STDs? ( ) 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 - If you don’t have any pictures to attach, will you pose for some?
( ) Yes ( ) No
I verify the Above Information is the Truth, So Help me God!!
___________________________________
Signature
___________________________________
Date