Please copy and paste, and email personally to Rachael@RachaelBenedict.com

First Name
Last Name
Your phone number - I will not call you unless it's at a mutually agreed upon time!
City/State of Residence:
Age (I do not discriminate based upon age, it's just nice to know :)):
Occupation: Brief description of who you work for and what you do...
Our time together:
___ Limited Lunch Affair (starting only between 10am and 2pm -2 hours) - $500
___ Classic Dinner Date (3-4 hours) - $750
___ Ultimate Dinner Date (6-7 hours) - $1000
___ Short Overnight (12 hours) - $1250
___ Full, Waking, Day (12 hours) - $2000
___ Medium Overnight (14 hours) - $1500
___ Long Overnight (18 hours) - $2000
___ 24 Hours Together - $2000
___ Travel Together (please elaborate)
If flying into STL the day we will be together: Airline and Flight # (... because you cannot call or text me if you are flying in circles around STL or if your flight had to be diverted ;-)||
What day and time would you like to meet?
What are your restaurant or dining preferences?
Where will we be spending our private time together at? (If my Romantic Retreat, please note extra screening requirements; Otherwise please specify your hotel, or if a residence, please put the closest intersection).
Your Introduction
What attracted you to contact me?
Reference #1 (email)
Reference #2 (email)
P411, DateCheck ID, Message Board Handles, etcetera:
Other places & ways to verify you online (work email, LinkedIn profile, etcetera):
How did you find this site?