Information Form

Consultation by Mail

INFORMATION FORM

If you want to consult us by mail, please print, then complete this form in full and mail it to us. For our Postal Address click here Services And Payment DetailsPlease click here for list of services and charges . Your request must include your Time of Birth,Place of Birth,Date of Birth. You must include a signature.
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Personal Information
Last Name:		First Name:
Middle Name:		Date of Birth:	Time of Birth:
Place of Birth:			Home Phone (optional)

Address Information
Present Address			Apt. #
City	Province	Postal Code	Country
Prefered Address (if you want to receive reply at different address than your present address)			Apt. #
City	Province	Postal Code	Country

What's the Problem ? Details/History of Problem
Full Details

I am the person named above and I understand and agree to theTerms&Conditions 0f Use. I could be prosecuted under law of Country for obtaining information/consultation/services from Vedic Medical Astrology.Com by fraudulent means or under false pretences.
Signature			Date
Revised December 31, 2004