Vedic Astrology Mail-In Order Form

Mail-In Order Form

Fill in and mail this form to:

Robert A. Koch
760 NW Broken Arrow Road
Bend, OR 97701-9037

Your Name___________________________________________________

Address ______________________________________________________

City/State/Zip__________________________________________________

Daytime Phone______________________________

E-Mail Address_____________________________

Male Female (Circle One) Date of Birth __________________ Time of Birth ____________________

City/State/Country of Birth_______________________________________

What issues would you like addressed in your reading?

_______________________________________________________________________

Please check which product you want.

____ Detailed Life Reading: $150
____ Abridged Life Reading: $110
____ Yearly or Bi-Yearly Update: $90
____ Moon Transit Calendar: $45 ($35 with any of the above readings)

Amount Enclosed: $_____________

Thank you for your order!

Home Services Order Meet Robert