PAST LIVES READING
by Loretta Marie
MAIL ORDER FORM
ORDERING INSTRUCTIONS:
Print Out Mail Order Form then Fill in All Pertinent Information!

Today's Date: ________________________

I Give Loretta Marie Permission to Conduct a Past Lives Reading:  Yes________

Please Choose One:
Email My Information: Yes___ No___             Send My Information Through the U.S. Mail: Yes__ No____

Paying By: (check one)
Money Order_____  Cashier Check_____  Personal Check_____  Credit/Debit Card_____

Amount Enclosed: $__________________________

Paying By Check or Money Order:
Make Cashier Check, Personal Check or Money Order Payable to The Inner Light Shoppe

Paying by Credit/Debit Card:
Type of Credit/Debit Card:     Visa_____  MasterCard____  American Express___   Discover Card____
Name on Credit//Debit Card:_____________________________________________________________________________
Credit/Debit Card Number:______________________________________________________________________________
Expiration Date: ______________________   Security Code (last 3-Digits on Back of Card): ______________
Amount Charging to Credit/Debit Card:  $____________________________
Signature of Person on Card:___________________________________________________________________________

Billing Information:
Name:
_________________________________________________________________________________________________________________________
Address: ______________________________________________________________________________________________________________________
City: _______________________________________________________________ State:_______________ Zip Code: _________________________
Email Address: ______________________________________________________________________________________________________________
Day Telephone #:_________________________________________________________ Night Telephone #: ______________________________

Ship To: (Only if Different Than Bill To Address):
Name: ________________________________________________________________________________________________________________________
Address: _____________________________________________________________________________________________________________________
City: _____________________________________________________________________ State: __________________ Zip Code: _______________

Send Completed Mail Order Form and Payment To:
Special Services by Loretta Marie
P.O. Box 214988
Auburn Hills, MI 48326

Upon receipt of your Mail Order Form and payment, the information you requested will be sent to you within 24 to 48
hours (Email) and depending on your location you should receive your Past Lives Reading within 7-10 days (U.S. Mail).

Note: You must be at least 18 years old to have a reading.  All Past Lives Readings are conducted for Entertainment
Purposes Only.
Name of Person Who is
Having the Past Lives Reading:
  
Address of Person:
  
Birth Date of Person:
  
Time of Birth (if known)
of Person:
  
Birth Location of Person:
  
Name of Significant Other and their
Relationship to the Person Who Is
Having the Past Lives Reading:
  
What Type of Past Lives Reading:
Basic, Deluxe or Full
  
Write at Least Three Questions of
Major Concerns:

Use Back of Paper if you need more
space!
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SPECIAL SERVICES
BY LORETTA MARIE
All Rights Reserved

Copyright 2012,
Spiritual Consultations
by Loretta Marie