ORDER FORM–ASTROLOGY CHART FROM PAMELA COLE

This is a secure transaction.

If you prefer to order by phone or mail…


BIRTH INFORMATION FOR
PERSON REQUESTING CHART:
(Enter your data carefully! We want to make sure it's YOUR life's blueprint we're reproducing!)

First/Middle Name:

 Last Name:
 Gender:

DATE OF BIRTH:

Month: Day: Year: (example–1953)

TIME OF BIRTH: (12 hour clock, not military). (example–1:16 p.m., NOT 13:16). The computer will make all the adjustments for daylight savings time, and time zones, etc.


(Be as accurate as possible about your time of birth. Refer to your birth certificate if you can. If it is not accessible, you may need to question those present, or in contact with, those present at your birth to ascertain an accurate birthtime).

PLACE OF BIRTH:

City

 

State

 

Country

EMAIL ADDRESS (Important! Pamela will contact you via email as well as mail your chart and interpretation to you.)

ADDRESS AND PAYMENT INFORMATION:

NAME ON THE CREDIT CARD:

First:

 

Middle Initial:

 


Last Name:
Mailing Address: (include apartment or suite number, if applicable)
City:


 State:
 Country:
 Zip:
Home Telephone: (include area code, or country code and area code if out of the U.S., please)
Work Telephone:
Credit Card Type:

Credit Card Number: (example 6011-0000-1111-2222)

Expiration Date: (example 01/02)

Additional Comments:

Do you need a response to your comment? If yes, please provide your EMAIL ADDRESS IF DIFFERENT FROM THE ADDRESS GIVEN ABOVE.



Email Address:
By "sending this order" you authorize Eupsychia Institute to charge your credit card $100 U.S.

 

 

You may also call-in your order to us on our toll-free line (800) 546-2795. Please have your birth and credit information ready. When calling, ask for BRENDA. You may also mail your order to us at the address below. When ordering through the mail, please provide us the information requested on this form, with the exception that checks and money orders are accepted by mail. Thank you.

Contact Pamela Cole about your chart
Contact Eupsychia about your order

Eupsychia Institute • PO Box 3090 • Austin, TX 78764
(800) 546-2795 • (512) 327-2795 • Fax (512) 327-6043

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