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Name Of Client:*

Email Id:*

Phone No:*

Date of Birth:

Time Of Birth

Place Of Birth:

State Of Birth:

Country Of Birth:

*Gender

Date Of Marriage:

Date Of Divorce:

Number Of Children:

Number Of Boys:

Number Of Girls:

City Living In*

Country Living In*

Occupation*

Attach Photographs Of Both The Sides Of Both The Palms If Date & Time Of Birth Is Not Available

*Has Any of Your Family Member Ever Suffered From Disease Of Any Kind Of Cancer / Kidney Failure / Paralysis / Brain Stroke / Tumor / Coronavirus / Tuberculosis / Heart Attack / Heart Failure / Paralytic Attack / Parkinson's Disease / Muscular Dystrophy / Nill

Yes

Please mention Name Of that Person & Complete Birth Details i.e. Date Of Birth, Time Of Birth, Place Of Birth, Date Of Marriage ( If Married ) Of The Person & Disease He / She is suffering from or please fill a completely separate form for that person giving the refernce of yourself.

Name

Date of Birth

Time of Birth

Place of Birth

Date of Marriage

Disease He / She is suffering from

*Do You want Consultation ?

Personal Consultation

Phone Consultation

Describe Your Queries / Problems Briefly:*

Do You want to consult through Birth Details, Horoscope (Kundli) Or through Palmistry (Hand Readings)

Do You want to do payment by depositing CASH in the Bank Account ?

Yes

Do You want to do payment by Internet Transfer / Net Transfer / Wire Transfer / Mobile Banking / Paypal ?

Has someone recommended you about Mr. Rajat Nayar ?

Yes

*How did you get to know about Mr. Rajat Nayar ?

*Are You or Your Family an Old Client Of Mr. Rajat Nayar ?

Yes

*I agree to all the terms & conditions. I am fully aware that there is NO FREE Consultation of any kind.

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