Midwest Striptease U.S.A.

All deposits for booked dances and parties are non-refundable

WE ACCEPT

OVER THE PHONE

:: Please complete *ALL* the fields in the form below ::

CONTACT INFORMATION

First Name:            Last Name:

E-Mail:           Phone (10 digits with no spaces/dashes):

Street or PO Box Address:

City:        State:           Zip Code:

PARTY INFO

Kind of stripper?:              Party Day:             Party Month:             Date:

Earliest Start Time:       Latest Start Time:

Party Street or PO Box Address:

City:        State:           Zip Code:

Approximately how many people will be attending:

Comments or special instructions:

NO REFUNDS AUTHORIZATION FOR PERSONAL LIABILITY

By typing your name in the adjacent box, you hereby understand and agree that you will not receive a refund after you press
'Submit' due to cancellations, oversights, or otherwise circumstances and personal liability on your part.

No bookings will be accepted without your electronic signature!

Electronic signature:

CONTACT INFORMATION
First Name: Last Name: E-Mail: Phone (10 digits with no spaces/dashes): Street or PO Box Address: City: State: Zip Code:
PARTY INFO
Kind of stripper?: Party Day: Party Month: Date: Earliest Start Time: Latest Start Time: Party Street or PO Box Address: City: State: Zip Code: Approximately how many people will be attending: Comments or special instructions: NO REFUNDS AUTHORIZATION FOR PERSONAL LIABILITY By typing your name in the adjacent box, you hereby understand and agree that you will not receive a refund after you press 'Submit' due to cancellations, oversights, or otherwise circumstances and personal liability on your part. No bookings will be accepted without your electronic signature! Electronic signature: