Name:........... Age:.............. Location:...... Status:.......... E-mail:........... Height: ......... ...... Weight: Smoker: ........ yes no No. of children ( if applicable ) : Occupation:.. Monthly Income: Circumsize: . yes . no Based on your experience are you a: Beginner Curious More than 5 yrs Whole Adult Life Submissive desired to be: Full time Part time Both Are you willing to visit Goddess Akira even for 3 time's a year? ......... Yes No Explain why you choose GoddessAkira? Are you willing to communicate to Goddess Akira ? How ? Explain... Have u ever and/or are you currently taking ANY medication for Depression, Anxiety disorders or neurosis? Please make a health statement addressing BE HONEST STD status.... Please tell me about your personality, Any other things or slutty behaviors I should know about since I love a good slut?