Fill in and mail this form to:

Robert Koch
760 NW Broken Arrow Road
Bend, OR 97701-9037

Address ______________________________________________________

City/State/Zip__________________________________________________

Daytime Phone______________________________

E-Mail Address_____________________________

Male      Female (Circle One)

Date of Birth __________________
Time of Birth ____________________
City/State/Country of Birth_______________________________________

What issues would you like addressed in your reading?

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

Please check which product you want.

(If you would like to have the recording done during a phone conversation, place a check mark in front of "By phone.)

____ Basic Life Reading: $225   __ By phone
____ Detailed Life Reading: $300   __ By phone
____ Relationship Compatibility, 60 minutes: $195    __ By Phone
____ Relationship Compatibility, 90 minutes: $225    __By Phone
____ Yearly Update 60 minutes: $175   __By Phone
____ Yearly Update 90 minutes: $195   __By Phone
____ Moon Transit Calendar: $45
      ($35 with Basic Life Reading or Yearly Update. Free with Detailed Life Reading.)

Amount Enclosed: $_____________

Thank you for your order!