Dating Form

Contact Information

First Name*

Last Name*

Phone Number*

Your Contact Email*

Plan Selection*

Order Summary

Price: $ 45.20 CAD

30 minute Phone: $40.00
HST: $5.20

Order Summary

Price: $ 84.75 CAD

60 minute Phone: $75.00
HST: $9.75

Order Summary

Price: $ 113.00 CAD

60 minute Skype: $100
HST: $13.00

Order Summary

Price: $ 169.50 CAD

60 minute in Person: $150.00
HST: $19.50

Order Summary

Price: $ 169.50 CAD

Online Dating Profile Writing $150
HST: $19.50

Grand Total

$ 0.00 CAD

Name*

Company

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Credit Card*

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

*

Name

This field is for validation purposes and should be left unchanged.