| Your name: | |
| On what date? | December 31, 1969 |
| If making a telephone inquiry, how was the receptionist? | |
| If your appointment was an incall, was the escort's place clean, tidy and comfortable? | |
| How would you rate your escort in terms of appearance and attire? | |
| How would you rate your escort in terms of attitude and service? | |
| Compared to other escorts you may have used, how would you rate your total experience with this escort? | |
| Will you use us again? | |
Comments: |
|