Confirmation form / 預約表格
Please input your information. / 請填寫你的個人資料

Please input in english. / 請用英文填寫
* must be complete / 輸入必需
Gallerria
Name / 姓名*
Hotel address / 酒店地址*
Hotel name or your address
(private address)
/ 酒店名稱

Room no. / 房間編號
Type of room / 房間種類
Mobile phone or contact info / 手提或聯絡電話*
Email address / 電郵地址*
Nationality / 出身国*
Ethinticity / 膚色
Confirmation day / 預約日期*
Confirmation time / 預約時間* :
Number of people / 人數
Course / 服務内容
Option / 追加内容
Desired type of girl / 希望的女性形象

ex) big breasts, slim / 胸大,苗条,等

Name of hoping girl (up to 3 people)
希望指名的女性(3名以下)
1.
2.
3.

Please leave it to the shop after asking hope. / 請聽希望之後委託給店

Credit card / 信用卡

Some store cannot be use. / 有部份店舖不能用

Remarks / 備註

Clothes on that day (only for Meeting service)
當日的服裝(只是赴約會合者)

please read the shop detail, notes and the prohibited matters are understood. The violate act promises the thing not done. Moreover, even any trouble to be involved in the shop, "japan-escort.net" will not take any responsibility.
請詳閱及理解店舖的注意事項和禁止事項,不要作出任何違反約束行為.此外,在店舖發生任何糾紛, 「japan-escort.net」概不承擔任何責任。

Agreement / 同意
Confirmation