This form must be filled out FULLY!

Your name: (as in your identification)
Email address:
Date of Birth
Your picture in URL
Address:
City:
State and Country:
Zip code:
Occupation:
Income:	$9,999 -$24,999 $25,000- $34,999 $35,000 - $49,999 $50,000+
Work Email:
Wife's Name:
Yahoo ID:
Home Phone:
Work Phone:
Amount of Tribute:
Desired Training:	Online Only Online Leading to Real Time Real Time Only Phone
Marital Status:	Single Married Separated Divorced
Employment Status:	Full-Time Employment Part-Time Employment Unemployed Retired Independently Wealthy Student
Are You Interested In Financial Domination?	Yes No
If Yes, How Much Are you Financially Able to Tribute Monthly?	$1000+ $900-$1000 $800-$900 $700-$800 $600-$700 $500-$600 Under $500
What Tribute Method Do You Intend To Use?	From pay button on site: Paymonde.com Mail Cash! Moneybookers
Tribute Schedule:	Daily Weekly Monthly
	Other:
Do you own a cam or are you able to purchase one within 2 weeks?	Yes No
Are you currently owned or serving another Mistress?	No, Not Owned Or Serving Yes, Owned and Serving Yes, Serving, but not Owned

Which of the following are you interested in exploring/experiencing? (Check All That Apply)

Humiliation	Sissification/Cross Dressing
Financial Slavery	Cuckolding
CBT	Enforced Chastity
Punishment/Spanking	Tease And Denial
Verbal Abuse	Foot Worship
Ass/Body Worship	Bondage
Smothering	Trampling
Strap-On Training	24/7 Servitude

NOTE:  Tell Me about yourself, your dirty little secrets,
and how you plan on serving me..

You will need to establish that your interest is sincere... Once you have submitted your application, you will be asked to send a small tribute as a token of your interest in Me.

Applications that are not accompanied by a tribute will not be considered. The link to the tribute page will be provided once you submit.

By submitting this form, you are agreeing that you are a serious slave with a serious interest in submitting and serving Me, Miss Samantha.  Your IP address is being recorded, should you be foolhardy and submit a false slave application to Me, the consequences WILL BE  LIFETIME banishment from accessing my website, yes I have the ability to do this boy...

You know what to do next, darling...

(CLICK ONLY ONCE! It will reach ME)