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My name is:
A good e-mail address to reach me at is:
My primary telephone number is:
and my mobile phone is
(if different from above):
   
Date of encounter:   at for a appointment
   
I'd very much like to see:
   
I'd like to meet my companion at:
If coming to me, my place is a:
Hotel/Business name (if applicable):
 Room#
The contact number at this location:
Address 1:
Address 2:
City:
Here's some further info about this location:
(if applicable)
   
Anything else you would like to tell us about this appointment?
 
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