= Required Field  
 

*First Name

*Last Name

*Contact Email Address

*Contact Phone Number

*Choose a Password

*Select a security question

*Answer to security question

*Who referred you to LGN

 
 

*Ad / Stage Name of person(s) being marketed in the advertisement

*Email address to display on your ad

Website URL to display on your ad

 
 

.
*Which option best describes your gender?

*Affiliation: Independent Agency

*Age:

*Height: feet / in meters / cm

*Weight: lbs kg

*Cup Size:

.
*Measurement:
(xx-xx-xx) inches

*Ethnicity:

*Available to: Men Women
Groups Couples

 
 

.
*Please select the city site you would like to place an ad on:

*Are you interested in a Base or Visiting ad? Base Visiting

*Categories your ad will appear in? Escorts Masseuse Sexy Maids Bachelor Parties

*Type of membership? click here to view membership details.

*Will you be offering incall and/or outcall? Incall Outcall

 

.
*Tagline for your ad:
.

*Bio text:

Additional Instructions: You may provide any additional instructions or inquiries for LocalGirlsNow staff
in this space. Please do not include your credit card number in this form as it is not a secure method of
transmitting sensitive financial information. The information you enter here WILL NOT appear on your ad. .

 
 

By using this website and/or submitting the submission form and information below, you agree to our Advertiser Agreement. You agree that the Advertiser Agreement is not tied to a specific ad and will apply to all content and materials submitted prior to, on, or after the submission of this document. We reserve the right to refuse any ad or content submitted by entertainers.

THE ADVERTISER AGREEMENT IS A LEGAL DOCUMENT GOVERNING OUR RELATIONSHIP. PLEASE REVIEW CAREFULLY.


You further agree that the laws of the United States of America shall govern this transaction.

To submit your information to us and sign the Advertiser Agreement, you must certify and affirm, under the penalties of perjury, either (a) if you are the person being marketed in the advertisement your actual date of birth or (b) if you are the representative of the person or persons being marketed in the advertisement, the actual date of birth of the youngest person, in each case, in the following Birth Date Verifier™ form.

*I am: The person being marketed in the advertisement The representative of the person(s)
being marketed in the advertisement

"I hereby affirm, under the penalties of perjury pursuant to Title 28 U.S.C. §1746, that I am an adult over the age of eighteen (18) years of age (or older, if the age of adult status is greater than 18 in the jurisdiction where I am located)."

"I hereby affirm, under the penalties of perjury pursuant to Title 28 U.S.C. §1746, that either (a) if I am the person being marketed in the advertisement that I was born on the following month, day, and year or (b) if I am the representative of the person or persons being marketed in the advertisement that the youngest person was born on the following month, day and year:"

If you are a minor, please leave this site now. If you are not a minor and you are at least 18 years old and entered an incorrect date, please review your entry and make appropriate corrections.

*Your birth month:    *Your birth day:     *Your birth year:

"I hereby affirm, under the penalties of perjury pursuant to Title 28 U.S.C. §1746, that all persons depicted in any pictorial representation in the content and materials that I have submitted or am or will be submitting were adults over the age of eighteen (18) years of age (or older, if the age of adult status is greater than 18 in the jurisdiction where the persons were photographed), at the time that said persons were photographed, in connection with the creation or production of the content or materials."

"I hereby affirm, under the penalties of perjury pursuant to Title 28 U.S.C. §1746, that I own, or possess the legal authority required to transfer, the necessary rights to permit the posting, publication and display of the content and materials I have submitted, or am or will be submitting, on your websites, including, without limitation, all copyright, trademark and trade name rights, supported by all necessary model releases of all persons appearing in said content and materials, including waivers of all necessary rights of publicity, commercial exploitation and privacy."

"I also agree that this transaction is governed by the Electronic Signatures in Global and National Commerce Act (E-Sign Act), 15 U.S.C. §7000, et seq."


Providing a false declaration under the penalties of perjury is a criminal offense. This document constitutes an un-sworn declaration under federal law. You may print this form for your personal records. You have the right to withdraw your consent to use the E-Sign Act by emailing us. Your consent to use the E-Sign Act is limited to providing the information on this form. Access to this electronic record requires a simple browser program such as Internet Explorer™ or Netscape™ and a computer. You adopt the mark typed in the form below as your electronic signature.

*Ad / Stage Name of person(s) being marketed in the advertisement:

*Your Legal Name:

*Signed: