Birth Time Rectification Order Form
Instructions: 
1.	E-mail your order to us. Prepare a short e-mail letter containing the information required on the Order Form and e-mail it to: Acharya@paramhansa.com.
When completing the Order Form, note these points:
o	Type or print clearly. Double-check your entries.
Spell out all dates: e.g., April 3, 1903...Not 4/3/03 or 3/4/03.
o	Supply the most accurate birth time you know. Check your birth certificate, family records, or some reliable source to obtain this information.
o	The personal information you supply - e.g., male or female, married or single, occupation, number of children, and so on will be used to verify the correctness of the astrological chart prepared using your birth data.
o	Include a return e-mail address so that we can acknowledge your order. Also, if the astrologer requires further information, we will contact you by e-mail. 
o	All the payment of orders must be payable in US dollars and at our Paypal Account admin@paramhansa.com 

Mailing Information 
Name (First, MI, Last): _________________________________________________________ 
Street address: _______________________________________________Apt:____________ 
City: _______________________________________State: ___________Zip: ___________ 
Country: ____________________________________
Phone: (_______)___________________ E-mail address: ___________________________ 
Have you had a Jyotish horoscope from ParamHansa before? Yes / No (Circle one)
Birth Information 

Date of Birth (Month/Day/Year): ______________________________________ 
(Please spell out the month & date; e.g., April 3, 1967; September 19, 1938)

Approximate Time of Birth (Hours/Minutes ): _____________AM or PM ?_______ (e.g., 9:06 PM) 

From birth certificate, mother, family records, other (Circle one) 

Time Zone (if known): ___________________________ (e.g., Pacific Daylight Time) 

Place of Birth / City: ________________________________ State: _________________ 

Country: ____________________________________

Longitude (if known): ___________________________ (e.g., W 123 deg 04 min) 

Latitude (if known): _____________________________ (e.g., N 44 deg 05 min) 
Personal Information 

The following information will help the Jyotish astrologer verify the correctness of the birth chart: 
Male / Female (Circle one) 

Married / Single / Separated / Divorced / Widowed (Circle one) 

Number of children (e.g., 1 son, 2 daughters): 

______________________________________________________________ 

Profession/Occupation:

______________________________________________________________ 

Education:

_______________________________________________________________ 

Mother Living: Yes / No (Circle one)

Father Living: Yes / No (Circle one)

Number of Siblings (e.g., 1 sister, 2 brothers): 

________________________________________________________________ 

Please describe any body marks you may have, such as a birthmark, mole, scar, etc. 
(I have a scar on my right forearm. I have a small oval birthmark on my shoulder.) 

________________________________________________________________ 

Please give dates of 6 significant events in your life ( I was married on May 4, 1978; My first child was born on August 10, 1981.). 
1. 
2. 

3. 

4.

5.

6.

Payment Information 

___ I wish to have my birth time rectified: INR 11,000/- (for Natives living in INDIA) or US$ 150 
  
Total Amount: _______________ 
We Accept Dakshina / Payment   through RTGS/ NEFT/ Net Banking for Details, eMail to Acharya@paramhansa.com   
For Paypal our Account is “astrology@paramhansa.com”
 
Please allow 10 - 14 days for completion of your horoscope. Please indicate how you would like the report sent to you: 
  
___ E-mail.......to this e-mail address: ____________________________________________ 
( Please print legibly. Even slight errors will prevent transmission of e-mail. )
  
Please Note: 
A Jyotish astrological horoscope is the opinion of one person based on his or her training and experience in Vedic astrology. Another astrologer's opinion on any particular point may differ. The horoscope you receive should not be used as a substitute for advice, programs, or treatment that you would normally receive from a licensed professional, such as a lawyer, doctor, psychiatrist, or financial advisor. ParamHansa, Inc. makes no warranties or representations regarding the accuracy or significance of any aspect of the astrological horoscope, and cannot be responsible for any interpretation or use that may be made of it. 

E-Mail: Acharya@paramhansa.com