Rekindled Ancient Wisdom

Personal Power Symbol Order Form

Name or Business Name:

DOB or Date Business Started (dd/mm/yyyy):

Delivery Details:

Name: ______________________________________________________________________________

Address: ____________________________________________________________________________

Town/Suburb: _______________________________________________________________________

Postcode: ______________________________

State: _________________________________

Country: _______________________________

Contact Phone No: _______________________

Email: _________________________________

Payment Details:

Credit Card Type: Visa/Mastercard/Bankcard

Credit Card No: _______________________________________ Expiry Date: ____________________

Name on Card: _______________________________________

Signature: ___________________________________________

Card Holder Contact Phone No: __________________________

I have enclosed a cheque/money order/bank draft/credit card information for the amount of $AUD_____ for _____ Personal Power Symbols.

Each symbol costs $AUD 67.00 (incl. GST and postage) within Australia. For overseas orders, the cost is $AUD 75.00 (incl. postage). Please allow 3 weeks for delivery.

Send the completed order form to:

Ancient Perceptions
PO Box 884
Toongabbie NSW 2146
Sydney Australia

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