Do you want to be my slave well please copy and paste and email it to me cspice69@yahoo.com
Slave Application Form
Name: _________________________________________________
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Date of Birth: ___________________________________________
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Home City: _____________________________________________
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Occupation: ____________________________________________
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The following questions are designed to help me asses you as a submissive. Please
answer all the questions. Tick where appropriate.
Martial Status:
o Single
o Married
o Divorced
o Widowed
o Cohabiting
o Other (please specify) ____________________________________
Sexuality:
o Heterosexual
o Homosexual
o Bisexual
o Transsexual
Health Status:
o Spinal Problems
o Joint Problems
o Injuries
o High/Low blood pressure
o Diabetes
o HIV
o Other (please specify) ________________________________
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Have you had any major surgery in the past 5 years? o Yes o No
If yes (please specify) _____________________________________
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Do you wear contact lenses ? o Yes o No
Do you suffer from any phobias (i.e. fear of incarceration, or claustrophobia)
If Yes, how does your phobia effect you ? _______________________
How long have you been a submissive ?________________________
Do you know where your submissive tendencies stem from ? _______
With regards to training my slaves, I subscribe to the notion of long term
development and personal training. This means that activities will not always be
focused on your own particular needs all the time.
How do you feel about this ? _________________________________
How subservient do you think you are:
o Not very subservient
o Fairly subservient
o Very subservient
o Completely subservient
How often are you used (have sessions with Domina’s) ?
o Weekly
o Fortnightly
o Monthly
o Yearly
o Other (please specify) ____________________________________
I do not feel that relief is of primary importance to a session, and as such I personally
will never relieve you. You may at times be in a privileged position of being allowed
to relieve yourself.
How important is relief to you:
o Not important
o Sometimes important
o very important
If you answered very important, please explain why: ______________
On a scale of 1 - 10 how would you define your pain tolerance:
No Pain Moderate Pain Extreme Pain
o o o o o o o o o
Which of the following dispositions would you most hope to find me in:
o Arrogant
o Cold
o Condescending
o Critical
o Cruel
o Demanding
o Humorous
o Intense
o Kind
o Playful
o Refined
o Relaxed
o Sadistic
o Unapproachable
o Understanding
I tend to wear whatever I choose, however, sometimes I may feel like treating you.
Which of the following would you most like to see me wearing:
o Leather
o PVC
o Rubber
o Uniform
o Boots
o Stilettos
o Stockings (no lingerie)
o Other (please specify) : __________________________________ _
Degrees of marking (the extent to which I can mark you):
o Hours
o A day
o Several days
o A week
o Weeks
o Permanently
Do you use Amyl in a session ? o Yes o No
Which of the following would you say were activities you enjoyed as a submissive:
o Anal training (Dildos/strap-ons)
o Asphxiaphillia (Breath play)
o Bondage
o Branding
o Caging
o Candle wax
o Chastity Devices
o Cling Film
o Cock & Ball Torture
o Cross dressing
o Depilation (shaving)
o Deep Heat Treatments
o Discipline (spanking, whipping)
o Electro Torture (PES, TENS)
o Fisting
o Foot Worship
o High Heel Torture
o Humiliation(Physical/verbal)
o Kilsmaphilia (Douching/enema)
o Masks (Hoods)
o Needle Play (Piercings)
o Nipple Torture
o Retifism (Shoes/boots)
o Sensory Deprivation
o Suspension
o Voyeurism
o All of the above
o Other (please specify) ____________________________________
As I am a lifestyle Domina, I sometimes like to involve third parties into my sessions
(other dom’s, female friends, & other slaves). These third parties may or may not
take on an active role within the session.
How do you feel about third party participation ?
o One-on-one sessions only - No third parties
o Occasional third party - With no active involvement
o Occasional third party - With active involvement
Give me a detailed account of one of your favourite submissive fantasies/fetishes:
1) ______________________________________________________
Now give me a detailed account of one of your worst submissive nightmares:
2) _____________________________________________________ _
During you stay with me what behaviour would be typical of you:
o To be usefully integrated into my day as a humble servant for all my demands
o To be used as an object for punishment to balance my mood
o To realise your inferior position and the need to become cultivated
o To perform in humble positions for my amusement
o To be traditionally disciplined by me
o To escort the me to restaurants, clubs, the theatre & opera etc.
o To express your feminine side
Do you have any expectations about coming to serve me? o Yes o No
If yes, please explain further:
I occasionally film & photograph session. Is this something that you feel you would
like to indulge in? o Yes o No
Do you have special skills you would like to mention ?
How did you hear about me ?
Use the following space to tell me anything else that you think may be relevant and
ofimportance to me: ___________________________ __
Disclaimer: I the undersigned do hereby state that the session in which I have
undertaken to be a submissive participant in is of my own free will, and at no point
have I been coerced or forced into participating.
Signed: _________________________________________________
Print Name: ______________________________________________
Date: ___________________________________________________
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