*For us to be able to contact you, you need to make sure all of your contact information is correct

Contact Information: 

 Miss Mr.  Mrs.  Ms.

 First Name:    Last Name:

    Email address :  (check that this is correct)

Date of Birth:     Month: JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Day: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31   Year: 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908

Mailing Address : Apt. #

City: State: AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDist. of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLousianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Other:

Postal Code: Country: AfghanistanÅland IslandsAlbania AlgeriaAmerican SamoaAndorra AngolaAnguillaAntarctica Antigua and BarbudaArgentinaArmenia ArubaAustraliaAustria AzerbaijanBahamasBahrain BangladeshBarbadosBelarus BelgiumBelizeBeninBermuda BhutanBoliviaBosnia and Herzegovina BotswanaBouvet IslandBrazil British Indian Ocean territoryBrunei Darussalam BulgariaBurkina FasoBurundi CambodiaCameroonCanadaCape VerdeCayman IslandsCentral African Republic ChadChileChinaChristmas IslandCocos (Keeling) IslandsColombia ComorosCongoCongo, Democratic Republic Cook IslandsCosta RicaCôte d'Ivoire (Ivory Coast)Croatia (Hrvatska)Cuba CyprusCzech RepublicDenmark DjiboutiDominicaDominican Republic East TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritrea EstoniaEthiopiaFalkland Islands Faroe IslandsFijiFinland FranceFrench GuianaFrench Polynesia French Southern TerritoriesGabonGambia GeorgiaGermanyGhanaGibraltar GreeceGreenlandGrenada GuadeloupeGuamGuatemalaGuinea Guinea-BissauGuyanaHaitiHeard and McDonald IslandsHondurasHong Kong HungaryIcelandIndiaIndonesia IranIraqIrelandIsrael ItalyJamaicaJapanJordan KazakhstanKenyaKiribatiKorea (north)Korea (south)Kuwait KyrgyzstanLao People's Democratic Republic LatviaLebanonLesothoLiberia Libyan Arab JamahiriyaLiechtensteinLithuania LuxembourgMacaoMacedonia MadagascarMalawiMalaysia MaldivesMaliMaltaMarshall IslandsMartiniqueMauritania MauritiusMayotteMexico MicronesiaMoldovaMonaco MongoliaMontserratMorocco MozambiqueMyanmarNamibiaNauru NepalNetherlandsNetherlands Antilles New CaledoniaNew ZealandNicaragua NigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorway OmanPakistanPalauPalestinian TerritoriesPanamaPapua New Guinea ParaguayPeruPhilippines PitcairnPolandPortugalPuerto RicoQatarRéunionRomania Russian FederationRwandaSaint Helena Saint Kitts and NevisSaint LuciaSaint Pierre and MiquelonSaint Vincent and the Grenadines SamoaSan MarinoSao Tome and Principe Saudi ArabiaSenegalSerbia and Montenegro SeychellesSierra LeoneSingapore SlovakiaSloveniaSolomon Islands SomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSpainSri Lanka SudanSurinameSvalbard and Jan Mayen Islands SwazilandSwedenSwitzerland SyriaTaiwanTajikistanTanzania ThailandTogoTokelauTonga Trinidad and TobagoTunisiaTurkey TurkmenistanTurks and Caicos IslandsTuvalu UgandaUkraineUnited Arab Emirates United Kingdom United States of AmericaUruguay UzbekistanVanuatuVatican City VenezuelaVietnamVirgin Islands (British) Virgin Islands (US)Wallis and Futuna Islands Western SaharaYemenZaire ZambiaZimbabwe

Home phone #: System phone #  (If available):

General Info:

 How long have you been doing readings?

 How long have you been reading professionally?

 What type of readings do you give?

  Have you ever taken calls for a phone network before?

Psychic Network History:  (Please list only professional, commercial lines you have worked)

 1. Company/Network/Line:  For how long?

Reason for leaving?  

 2. Company/Network/Line:  For how long?

 Reason for leaving?  

 3. Company/Network/Line: For how long?

Reason for leaving?

References : Please list 3 references that we can contact to verify your experience.

1. Name:  Email: Phone # :

2. Name:  Email: Phone # :

3. Name:   Email: Phone # :

 Additional Information: 

**Please list any additional information that will prove beneficial to this position.**

Thank you for taking the time to fill out the application.

We will be in touch with you soon.

Lisa Marie & David
Serenity's Northern New Age