ORDER FORM # 1

PLEASE PRINT THIS PAGE AND MAIL YOUR ORDER TO US. THANK YOU!

ORDER FORM

FULL ASTROLOGICAL REPORT

NAME:______________________________________________

ADDRESS:___________________________________________

CITY:__________________ STATE:__________ ZIP:_________

COUNTRY:___________________

PHONE # : ___(___)_______________We might need to call you, should we have any questions.

E-MAIL ADDRESS: _________________@__________________

DATE OF BIRTH: ________________

TIME OF BIRTH: _________________ ____AM ____PM

PLACE OF BIRTH:

CITY _________________ STATE__________________ COUNTRY _______________

YOUR ORDER WILL BE MAILED TO THE ABOVE ADDRESS.

PAYMENT BY: PLEASE CHECK ONE.

___PERSONAL CHECK ___MONEY ORDER

Please make your check for $ 19.95 plus $3.00 shipping , International Orders $19.95 plus $6.00 shipping U.S. unds Only to: EMSA TECNOLOGIES, INC.

Mail your order to us:

EMSA TECHNOLOGIES, INC.

P.O. BOX 8927 DEPT W.

PALM SPRINGS, CA 92263