Astrology House Order Form

Please print page and fax or post to Astrology House, 147a Centreway Road, Orewa 1461, New Zealand.
Tel/fax + 64 9 421 0033. Or e-mail details requested in form to:

__________________________C____________________________

First Name______________________________Last Name____________________________

Address_____________________________________________________________________

Phone Number___________________________Fax Number__________________________

E-mail Address_______________________________________________________________

Type of Chart, please tick: Natal Chart ($NZ175)_________Annual Forecast ($NZ125)_______

Date of Birth:

Day______________________Month_____________________Year____________________

Place of Birth:

Town_____________________________Country____________________________________

Time of Birth:

Hour_________________Minutes__________________AM/PM

Accuracy of Birth Time: (Eg. Exact, 5 mins, 30 mins, 1 hour, Unknown etc)__________________

Source of Birth Data (Eg. Mother, Hospital Record etc)__________________________________

__________________
Method of Payment:

By cheque or money order please make payable to Astrology House

By VISA/Mastercard include:

Card holder's name________________________________________

Card No_______________________________Expiry date________

Total Payment:____________________________________________
 

Signed:___________________________________________Dated:___________________________



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