Your Name: *
sub/slave name (If you would like to use one):
Your email address: *
Age
Can you be contacted by phone? Yes No
Telephone number:
What phone is this?
Home
Business
Cell
Are you the only one who answers this phone number? Yes No
City, State, Country
Marital Status:
Single
Married
Divorced
Do you wear contact lenses? Yes No
If Diabetic, type I or II Not Diabetic Type I Type II
Are you Epeliptic? Yes No
Are you Claustrophobic? Yes No
Are you allergic to anything particular rubber? Yes No
Do you have a pace maker or any other devices in your body? Yes No
What medications are you currently on?
How did you find My Web Site?
Are you a true submissive?
Yes
No
Sometimes
I have no idea
How did your interest start?
How long have you been interested in the scene?
Newbie
A few months
Less than a year
1 year
2 years
3 years
4 years
5+ years
How often do you meet with a Mistress?
Once a week
Once a month
A few times a month
Several times a year
As often as I can afford it
Which Mistresses have you visited? Please list name, city and country.
When was your last session and with who?
What did you DISLIKE, if anything.
Which room would you like to experience? The White Room The Black Chamber The Powder Room The Sling Room The Domestic Room Web /Phone Training
What type of clothing do you prefer your Mistress to wear? (mark all that apply) Leather Rubber / Latex PVC Corsets / Waist-Cinchers Skirts Dresses Stockings/Garters Pantyhose Seemed Nylons Fishnets Loafers/flats sandal Jeans/Casual Wear Business Suit Nurse Uniform - Official white starch Nurse Uniform - Rubber/latex Nurse Uniform - PVC Nurse Uniform - Street clothes under Dr. coat Pumps Knee-High Boots Crotch-High Boots Open-Toed Stilettos Strappy high heel sandals
What are your favorite colors for mistress wardrobe undergarments? Red Black White Pink Silver Gold
For yourself, is there special clothing you would like to be wear during the session?
Can your Mistress mark you?
Never
A little
A couple of days
As long as it lasts
Limits: Please list your Off Limits or No Way!
Level of Play
Novice
Intermediate
Advanced
You are interested in: Mistress/slave/sub Nurse/Dr/patient Classroom/schoolboy Mother/auntie/babbysitter Employee/secretary/boss Sissy slut/x-dress/maid Interrogator/prisoner/kidnapping Classroom/schoolboy
Session dynamics: Compassionate Teased / Sensual Seduced No Pain Forced Clinical Light Pain Moderatly Strict / Moderate Pain Sadiscally strict/tourtoured/Mistress do not hold back
Degradation/Submissive Control humiliating acts private/public humiliating talk verbal abuse mild verbal abuse heavy verbal dirty words forced feeding golden shower body golden shower /mouth spit fantasy/ body spit/fantasy mouth face slapping enema fantasy diapers/baby lead on leash/crawling public shoping/outings open to anything to please the Mistress
Transformation panties garters /stocking pantyhose/full corset/waist cinchers wigs makeup makeup/ lipstick only lingerie/bras dresses/skirts Virgin bride/wedding dresss high heels boots innocent slutty prim & proper maid open to anything to please the Mistress
Medical enema/sensual, fantasy enema/forced, fantasy temp taking electrical play mild/intense strap-on,fantasy small/large vibrators / toys,fantasy speculums,fantasy needles /peircing,fantasy lacing/suturing,fantasy bladder stretching,fantasy pr exam/massage,fantasy catherthers/fanatasy open to anything to please the Mistress
Corporal spanking/hand spanking/over the knee leather paddle wooden paddle belt/strap rubber whip can/rattan deerskin cat leather cat braided cat riding crop open to anything to please the Mistress
Encasement bondage/moderate bondage/inescapable strenous bondage/hogtie chasity devices leather bondage latex/rubber bondage rope bondage silk scarfs chains/handcuffs plastic wrap mummification body bags arm sleeves staright jackets genital bondage/ rope spreader bars cages sling /harnesses stocks/pillarys st andrew crosses spanking horse suspension on toes suspension/ full hoods/hood gear gags open to anything to please the Mistress
Touture and Sensory Deprivation blindfolds headphones/earplugs tickling scratching feathers/furs pinching hair pulling nipple sensual touching nipple clamps/clips genital / cbt / torture genital / cbt / sensous ball stretchers ice menthol rubs hot wax kicking/trampling Fetishes/leather Fetishes/latex/rubber Fetishes/pvc Fetishes/panty Fetishes/stocking/garter Fetishes/heels/shoes Fetishes/bare legs Fetishes/boots Fetishes/gloves Fetishes/hand/nails Fetishes/foot/leg Fetishes/smoking
I would like to make an appointment with Mistress Victoria on the following date:
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
2010
2011
2012
I would like to make an appt with Mistress Victoria at this time:
Appointment length requested:
1 hr
2 hr
3 hr
4 hr
5 hr
6 hr
Multi-hour / Overnight
Acknowledgement (You must check this box to submit this application) * By checking this box and submitting this application I acknowledge that I have read Mistress Victoria's rules and understand that there is no sex involved in Mistress Victoria's sessions. I am also a consenting adult over the age of 21.
