Full Name:

Birth Data
Date: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month: January February March April May June July August September October November December Year: 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Birth Place
City: State: Country:

Birth Time: AM: PM: (from Birth Certificate or other reliable records)

Formal Education:

Training in Arts or Science:

Religious and Spiritual Training:

Hobbies or Special Interests:


Personal Data: Marriage(s) and/or Primary Relationship(s) Dates, etc.

Birth Dates and Gender of Children:


Employment History (dates jobs began and ended; description of responsibilities):

What is the most important thing you want the reading to help you achieve?

PLEASE READ, INITIAL AND SUBMIT TO COMPLETE YOUR ORDER

I hereby request you to inform me concerning the planetary forces active on the date of my birth and at other times during my life, as they are mapped by the Natal/Progressed Positions and Aspects of Scientific Hermetic Astrology. I affirm that my birth data, and whatever other information I supply on the Questionnaire, is accurate to the best of my knowledge.

In furnishing me this Astrological information, I understand that you obtain it from charts accurately computer-calculated using the Astrodyne method. I also understand that the Reading is NOT a computer-generated report, but rather an expert professional consultation personally recorded by you on audio cassette tapes.

I also understand that I am not asking you to "tell my fortune" in any sense, nor do I understand that you attempt or claim to do so. Instead, I realize that you will furnish me with thorough insight and understanding which, if I choose to act upon it, will enable me to have more complete self-knowledge and thereby improve my life experience.

Sincerely,

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