(Please copy and paste into an email and return to Me, Mistress Ultra Violet  promptly for consideration)
My email address is:

Date/Time/Duration you are requesting an audience with your Goddess___________________________________

Name and last initial______________________



Physical Description_________________________________________________________________________________________________________________

Marital Status__________

Financial Status and Employment Industry________________________________

Sexual Orientation__________________________

Medical Concerns/Physical Limitations_________________________________________________________________________________________________________________

Phobias/Abuse Issues__________________________________________


Can you be marked? If so, for how long?_______________________

How often do you wish to visit with Me, (Mistress Ultra Violet) Weekly? Bi-Weekly? Monthly? Bi-annually?_________________________________

Which attire do you prefer to see Me,(Mistress Ultra Violet) adorned in? (Please choose all that apply and delete the rest).
Latex dresses/skirts
Patent Leather
PVC/Vinyl pants/dresses/skirts
Business attire/suits
English riding apparel/boots
Corsets/waist cinches

Hosiery (please choose all that apply and delete the rest)
Cuban heel/seamed
Sheer black
Nude pantyhose
Black Knee-high
Bare legs/none

Shoes (please choose all that apply and delete the rest)
Thigh-high boots
Knee-high boots
High-heeled pumps (closed toe)
Peep-toe pumps or sandals (open toe)
Platform heels
Goth boots
Goth Platform shoes

Gloves (please choose all that apply and delete the rest)
Latex (opera length)
Leather (wrist length)
Satin (opera length)
Bare arms/none

In regard to My demeanor during the session, (i the submissive, would prefer:) (please choose all that apply and delete the rest)
Spoiled/Never satisfied

What best describes your reason for visiting Me? (please choose all that apply and delete the rest)
Suffering to please your Goddess and amuse Her (with disregard to my desires)___________________
Exorcism of guilt_____________
Other(please describe)_________________________

What would best describe the scenario you are seeking? (please choose all that interest you and delete the rest)
Schoolteacher/naughty boy
Female pimp/man-whore
Riding Mistress/ponyboy
Blackmailer/financial slave
Humiliatrix/small penis man
Mommy/Little boy
Other (please describe)____________________________________________________________________________________________________________________________

How long have you been involved in BDSM activities?_________

Do you have any other skills outside slavery that you can offer Me? How will you please your Goddess other than Her required tribute? __________________________________________

Do you have references from other Dommes (local,national or international)?__________________

Are you involved in any fetish/BDSM organizations? If so, which?_______________________________________________________

ACTIVITIES I AM INTERESTED IN: (please choose all that apply and delete the rest)
1.Bondage: Leather, Rope, Bondage tape, Saran wrap
Method: Light, Inescapable, Extended, Mummification

2.Corporal Punishment: Flogging, Whipping, Strapping, Spanking, Caning, Birching, Hairbrush

3.Genital Torture: Whipping, Chastity, Kicking/Kneeing,Trampling, Stretching/Weights, Chastity, Light touch cigarette, Hot wax, tight bondage/tying, manual squeezing/vise, slapping

4. Foot Worship: Stocking/Pantyhose, Shoe/Boot/Heel, Bare Feet
Method: Bootlicker, Toe Kisser, Masseuse, Footstool, Rug

Method: (please describe)____________________________________

6.Domestic Service Training (must be available with 2-8 hours notice): Chambermaid, Chauffeur, Foot slave, Dungeon Slut (forced-bi fantasy)

7.Shaving (yes, no or choose): Genital area, Body_____________

8.Smoking Fetish (Mistress smokes. Yes or No): Human Ashtray Service______________

9.Puppy Training (yes or no): Caging, dog food eating, leash training, costuming, verbal command training

10.Pony Training (yes or no): Show pony, cart pony, riding pony

11.Financial slave/Paypig/Blackmail (yes or no)___________

12.Cuckolding/Key-Holding CB-3000/6000/The Curve Long or short duration training

I love to entertain My guests. Are you comfortable being in a session/scene/show/party, with others:

Dominant Females
Dominant males
Submissive Females
Submissive males

(Confidentiality is of supreme importance to your Goddess.(I may use Masks to hide your identity).

All information held in the strictest of confidence Mistress Ultra Violet The name more Dungeon-going Americans trust!