Your Name: *

First Name

Last Name

Your Phone #: *

(###)

###

####

Date of Extragram: *

MM

DD

YYYY

Address of where you're sending the Extragram to: *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Is this a private or public residence? *

Private

Public (ex: restaurant, bar. If so, you MUST get approval from their management.)

Which type of Valentine Extragrams are you requesting? *

💖VALENTINES CUPID QUEEN PACKAGE w/ PERFORMANCE💖 $250

💖VALENTINES CUPID QUEEN PACKAGE 💖 $175

What type of place is this? *

House

Apartment/Condo

Hotel

Restaurant/Bar

Other

Can you answer "yes" to the following? *

I realize that music is played at a fairly loud level and I'm ok with that.

I will act in a respectful and appropriate manner during the performance

Would you like to add some EXTRA flare?

"Stay Extra" Clack Fan for $25

"Iconic" Hat for $25

"Stay Extra" Stickers (3 pack) $10

Full "Glam Bag" of all the above $50