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Harley Raines's Reservation Form

Please check my calendar to see when I am in your area.

* Please note that special requests require travel reimbursement.*

Your Privacy is Assured

Full Name:*
Email Address:*
Address:*
Date and Time of Appointment:*
City of Appointment:*
Name of Business or Employment:*
Work Number and Extension:*
Title or Position in Company:*
Cell number: *
Home number:
Age:*
Height:*
Weight:*
Hair Color:*
Other distinguishable features:
References-Other Porn Stars/Famous Escorts you have had appointments with:*
Any comments, questions or special requests?

An asterisk denotes a mandatory field. Please fill all required fields before clicking submit.

Note: If you are not taken to a Thank You page your reservations were not made.

 

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Copyright 2006 - 2007 Harley Raine Inc. All rights reserved.
Last modified: Sunday August 05, 2001.Revised: 18 Oct 2007 00:52:37 -0400 .