ORDER FORM # 2

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

ORDER FORM

COMPATIBILITY REPORT

PERSON # 1:

NAME:______________________________________________

ADDRESS:___________________________________________

CITY:__________________ STATE:__________ ZIP:_________

E-MAIL ADDRESS: _________________@__________________

COUNTRY:___________________

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

DATE OF BIRTH: ________________

TIME OF BIRTH: _________________ ____AM ____PM

PLACE OF BIRTH:

CITY _________________ STATE__________________ COUNTRY _______________

PERSON # 2:

NAME:______________________________________________

DATE OF BIRTH: ________________

TIME OF BIRTH: _________________ ____AM ____PM

PLACE OF BIRTH:

CITY _________________ STATE__________________ COUNTRY _______________

YOUR ORDER WILL BE MAILED TO PERSON # 1 AT THE ABOVE ADDRESS.

PAYMENT BY: PLEASE CHECK ONE.

___PERSONAL CHECK ___MONEY ORDER

Please make your check for $ 14.95 plus $3.00 shipping , International Orders $14.95 plus $6.00 shipping U.S. funds Only to: EMSA TECNOLOGIES, INC.

Mail your order to us:

EMSA TECHNOLOGIES, INC.

P.O. BOX 8927 DEPT W.

PALM SPRINGS, CA 92263