APPOINTMENT REQUEST FORM
*All fields marked in bold are required
Full Name
(Mandatory so you can be contacted)
E-mail address
(Mandatory so you can be contacted)
Type e-mail address again for verification
(Mandatory so you can be contacted)
Your contact phone number
(I will call you after you have made your deposit)
Mobile Work Home
Phone
Alternate contact number Mobile Work Home
Phone
Is it ok to leave a message on your voice mail if you do not answer?
(Check those that apply)

Mobile Yes, No
Work Yes, No
Home Yes, No
Where would you like to see me?
(Outcall is only available for Los Angeles. I only do incall when I am on tour.)
How much time would you like to spend with me?
Please make sure to check my rates.

What date and time would you like to see me?
In what city and state do you live?

,
What line of work are you in?

Have you seen another escort whom you could use as a reference? If so, who is she and what is her e-mail address and/or website address?

Name:

Email/website:
What method would you like to use for the deposit and remaining balance? Credit Card (your card will be discretely billed by Simply Pumpi Inc.)
Cash by overnight mail
Cashiers check by overnight mail.(Please make cashiers check out to Simply Pumpi Inc.)
I would love to know a little bit about you before we meet. Please share something of yourself.
Any additional information, comments or fun suggestions you would like me to know before we meet?

I may request additional information for verification upon submission of this form.