A Date With Kandice

A DATE WITH KANDICE
Reference 1 Information
Full Name *

First Name Last Name
Phone Number *

Area Code Phone Number
E-mail *
Reference 2 Information
Full Name *

First Name Last Name
Phone Number

Area Code Phone Number
E-mail

Date Information
In-Call or Out-Call *

Out-Call Address (High End Hotel Only, No private Residents) *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Start Time

Month Day Year
at
Hour Minutes AM/PM Option Date Picker Icon

Extended Date Selection
Date Packages *

12 Hour 24 Hour 48 Hour
Pay Deposit via Paypal now (not required to pay now, but is required to hold date)

No Thanks Free

Date Deposit $ 600.00
Balance Due 50% (Out of town Trips) *

Client Information
Name

First Name Last Name
Email
example@example.com
Phone Number

Area Code Phone Number
Should be Empty:

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