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Only fill this out AFTER you have sent me a $50 tribute

Once you have filled this form inn FULL with no spaces, I will then set about making you my property.

(Don't try to submit false information, as my personnel slave will check to make sure the information you supplied is correct!)

First Name: 
  
Last Name: 
  
Age: 
  
E-mail: 
  
Phone: 
  
Work Phone: 
  
Address 1: 
  
Address 2: 
  
City: 
  
State/Province: 
  
Country: 
  
Postal/Zip code: 
  
     
Are you married: 
   No Yes
Number of Kids: 
  
Yearly income: 
  
Brand of car: 
  
Credit cards that you have: 
   Visa
MasterCard
Amex
Diners Club
Total amount of credit you have available to you:
(not what you have already spent)
  
Money in bank accounts: 
  
Monthly Expenses: 
  
How much are you willing to pay your Goddess per month? 
  
     
Tell me a secret that is so embarrassing that you don't want anyone to know: 
  
Now who is the last person you want to know this: 
  
   
And what is their contact info.: 
  
Phone
Email
   
And last as well as least, what are your interests? 
  
Smoking Fetish   
Foot/Shoe Worship
Party Service
Pet Treatment
Forced Feminization
Maid Service
Tease & Denial
Infantilism
Spanking
Cross-dressing
Restraint
"Forced" Extortion
Financial Control
Humiliation-Verbal
     
Extra info.: 
  

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