Astrology Form Page

Please complete the following form and then either Submit the form or print it out and mail it to Judith at:

JUDITH AUORA RYAN
33 West 56th Street
Bayonne, NJ 07002

PHONE: 201-858-1689

E-mail

Contact Information

(Note: * represents a required field)

First Name*:

Last Name*:

Street Address:

2nd Line Address:

City:

State/Territory:

Zip (Post) Code:

Country:

Home Phone:

Referred by:

Email*:

Special Areas of Interest or Instructions:

Birth Information

(If you are requesting an Astrology or Feng Shui Consulation this needs to be completed.)

First Name:

(if different from above)

Last Name:

(if different from above)

Birth Date:

Month Day Year

Birth Time:

Hour Minute AM/PM
If the time is not known then 12:00 PM will be used.
You may be able to obtain your time at www.VitalCheck.com.

City:

State/Territory:

Country:

Sex:

Relationship Information

(If you are requesting a Love & Relationship Chart this the other person’s birth data.)

First Name*:

Last Name*:

Birth Date:

Month Day Year

Birth Time:

Hour Minute AM/PM
If the time is not known then 12:00 PM will be used.
You may be able to obtain your time at www.VitalCheck.com.

City:

State/Territory:

Country:

Sex: