PsyPlan(tm) Planner Order Form  (print & mail)
A 
D ___________________________________________
D
R ___________________________________________
E
S ___________________________________________
S
Phone ___________________ ___________________
       home                work
Name to appear
on the planner ______________________________

Birth date  ___ - ___ - ___  (month-day-year)

Time of birth ____:____  [] AM  [] PM  zone__
When birth time is unknown, we will use noon.

Place of birth ______________________________
                     city, county, state
Where will your
PsyPlan be used _____________________________
                     city, county, state

Begin PsyPlan with month of _________________

Text-   []ADZE []DICKEY []KEYWORD []NOVICE  
 style

Use precession of equinoxes?  [] yes  [] no

Size       wallet  pocket   booklet  notebook
(inches)   [](3x5) [](3x6)  [](5x8)  [](8x11)
           []custom (enclose a sample page)

Binding  [] Wire-O double loop wire comb
         [] folded and center-stapled
         [] hole-punched for ring-binder
                  (enclose a sample page)

[] planner - one monthly planner . . $17.00
[] calendar - annual forecast  . . . $21.00
[] suite - calendar, 6 planners  . . $70.00

Add S&H  []$5 Domestic  []$10 International

Mail check/money-order US$ to:
     John G. Derrickson
     236 W. Ridley Ave.
     Norwood, PA  19074-1510