EmailMe Form - Astrological Reading with Jon Waldrup

Purchaser Information

(The person buying the Reading)

Today's Date

MM / DD / YYYY

Name

First Last

Email

Phone

### - ### - ####

BIRTH DATE INFORMATION (all fields required, unless time is not known)

Only enter birth time if you are positive of its accuracy. Other methods are available ...PLEASE CONTACT JON IF YOUR BIRTH TIME IS NOT KNOWN.

Date of Birth

MM / DD / YYYY

Birth Time

Yes, I know my time below

No, I will contact you for more information

Time of Birth (9:10, 11:45, etc)

Choose One

AM

PM

If you know, please indicate whether you were born significantly early (gestation period of <38 or > 42 weeks.) and/or any other thing about your gestation and birth that you think might be worth mentioning.

Name of Birth City (ie, Chicago, Paris, Dallas, etc)

Name of US Birth State or Country

Comments

GIFT CERTIFICATE RECIPIENT (Fill info below only if you purchased a Gift Certificate)

(This information is of person receiving the Gift Certificate. Birth Information for actual recipient will be acquired before the reading. If you definitely know the above Birth info, then fill out appropriate form fields above.)

Name (required)

First Last

Email (optional)

Phone (required)

### - ### - ####

Approximate Date of Gift

MM / DD / YYYY

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