Reading Order Form
(Please print. Items in all CAPS are required.)

NAME:________________________________TELEPHONE:________________________

EMAIL ADDRESS:_____________________________Fax:________________________

PAYMENT METHOD:(Circle One) Mastercard - Visa - American Express - Discover - Check

CREDIT CARD NUMBER:______________________________EXPIRES:_____/______

SIGNATURE________________________________________DATE:_______________
        We require the following:
NAME AS APPEARS ON CARD:_____________________________________________
      BILLING ADDRESS 1:_____________________________________________
      MAILING ADDRESS 2:_____________________________________________(Required)
CITY:______________________STATE:_________ZIP/POSTAL CODE:__________

Select the items you desire.

Item                           Price         Selection

10 Minute Reading              $ 40.00          _____       
15 Minute Reading              $ 60.00          _____       
20 Minute Reading              $ 80.00          _____       
25 Minute Reading              $100.00          _____       

All prices are US dollars.

Name:___________________________________________

Address:________________________________________

State:__________________________ Zip:___________

Phone Number:___________________________________

Comments, Special Requests:

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

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