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Astrology Consultation Paid For!

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Astrology Consultation
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First Name* First Name*

Last Name* Last Name*

E-mail Address* E-mail Address*

Street Address

City* City*

State/Prov* State/Prov*

Zip/Postal Code

Country* Country*

Home Phone

My main problem is:* My main problem is:*

Date of birth* Date of birth*

Month of birth* Month of birth*

Year of birth* Year of birth*

Hour of birth* Hour of birth*

Minut of birth* Minut of birth*

How certain are you that the hour and minute of birth are accurate?* How certain are you that the hour and minute of birth are accurate?*

Place and country of birth* Place and country of birth*

When did you first start noticing the problem?

Any other comment?