NAME: ________________________________________________________________
ADDRESS: _____________________________________________________________
CITY: _____________________________________ STATE: _______ ZIP: __________
D.O.B (month, day, year): _________ / _______ / _________ (EX: FEB. 26,
1950)
TIME OF BIRTH: ______ : ______ AM__PM__ (Time is only needed for
Astro-cartography)
PLACE OF BIRTH (City, State, Country):
______________________________________
SECOND PERSON PROCESSING INFORMATION
NAME: ________________________________________________________________
ADDRESS: _____________________________________________________________
CITY: _____________________________________ STATE: _______ ZIP: __________
D.O.B (month, day, year): _________ / _______ / _________ (EX: FEB. 26,
1950)
TIME OF BIRTH: ______ : ______ AM__PM__ (Time is only needed for
Astro-cartography)
PLACE OF BIRTH (City, State, Country):
________________________________________
Credit Card Details-- Required credit card information
Total amount ___________
Card number ________-_________-_________-_________
Expiration date _______-_______
Customer contact information:
Name ____________________________________________________
Phone number ______________________________________________
Email address ______________________________________________
Billing address:
Street address _______________________________________
City ___________________________________________________
State ___________________________________________________
Zip code _____________________________________________
Purchase/product description:
_________________________________________________________
MAIL YOUR ORDER AND PAYMENT PAYABLE TO:
Dr. Turi
4411 N 23Rd St.
Phoenix, AZ 85016
Tel: (602) 265-7667 - Fax
(602) 265-8668