Verification

* Required Field

About You

First Name ( No alias ): *
Last Name ( No alias ): *
Age: *
Ethnicity: *
Email:
Phone: *
Industry/field of work:
Photo-Face Only:

Pre-screening

Provider Reference 1- name, email, phone, link to website or reviews:
Provider Reference 2- name, email, phone, link to website or reviews:
Online presence - Twitter, Switter:
Hobby Handles p411, TER, RS2K other:

Our Time

Our Time Together:
1.5 hours
2.0 hours
3 hours
Day - Girlfriend
Night - Girlfriend
Weekend Getaway
1.0 hour
Date/Time Appointment 1st choice:
Date/Time Appointment 2nd choice:
Appointment City:

Newsletter

Interested in my travel schedule..
Yes
No

Deposit/Cancellation Policy

I have read and understand the policy: *
Yes

  

 

 

 

 

Discretion is as important to me as it should be to you. My safety is as important to me as your safety is to you...

These two reasons are my basis for screening.

Everyone I see has to be verified.

Please use the form or send the necessary information via email to phemie@ebenedame.com and allow enough time for screening.

I'm not 24/7, so please allow 24hrs for verification process