First Name	Middle Initial
Last Name
Street Address
Street Address
City	, State Zip Code
E-mail Address
Phone	-- Ext.
Birth Date & Year
Birth Place	City , State
Birth Place	Country (If born outside USA.)
Birth Time	am pm
Source of Birth Time (i.e., birth certificate, etc.)
Please provide an explanation of the event you would like to have timed (if elective surgery, indicate type of surgery / if new business start, indicate type of business, etc.). Give me as much data as you can. I will contact you if I need further information.

Astrological Timing Service

Please print your completed form and submit with check or money order to the address below:

Cindy L. Suess

P.O. Box 2861

San Rafael, CA 94912

You can reach me with questions at (415) 472-1289 or email me at Cindy@depthastrology.com. It takes approximately 1 week after receiving your data before I contact you to discuss the timing of your event.