Request Form

Please fill out the following:
Your full name:
Address:
City:
State:
Zip Code:
Year:
Phone Number:(ex: 732-555-1234)
Cell Home
Male Female
Your e-mail address:
ex: relax@thedawnofanewage.com
@



I am writing to request the following:




Prayer choice #1:
The prayers to choose from are:
Angel Prayer
The Rosary
Jesus
The Violet Flame Prayer of St. Germaine
St. Francis
St. Rita
St. Anthony
The “Clear Intent” Prayer
Special Request
Prayer choice #2:
The prayers to choose from are:
Angel Prayer
The Rosary
Jesus
The Violet Flame Prayer of St. Germaine
St. Francis
St. Rita
St. Anthony
The “Clear Intent” Prayer
Special Request

because...


Signature* ________________________________________(only if mailing it with a payment)

Date: (mm/dd/yyyy) / /

Mail*: Release form, Request form and check or money order to:
The Dawn of a New Age
821 Mantoloking Road
Brick, NJ 08723

*If using PayPal, your payment is your signature. It is not necessary to mail it to us, but please fill out the above form, so that your distant healing/prayer is sent to you with the proper intent to help you. Back to Distant Healing