Please send the information listed below by sending as below, or by direct email to dallym@netspace.net.au

(if you just wish to send a message or make an enquiry simply put your name and go down to the MESSAGE section further down and SEND).
Full name of subject-person of entry:
Date and place of birth of that person:
Date and place of death of that person (if relevant):
- - - - - - - -
Person Submitting:
Date:   Surname:
Given Names: Title (Ms/Mr/Mrs/Dr etc):
Number and Street:
Town/City:
Zip or Postcode:
State and Country:
Phone numbers:
Fax: Numbers:
Email address:
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Secondary contact (Will be used if the submitter cannot be contacted)
Surname:
Given Names:
Title (Ms/Mr/MrsDr etc):
Number and Street:
Town/City:
Zip or Postcode:
State and Country:
Phone numbers:
Fax: Numbers:
Email address:
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Other persons who should be acknowledged on the site (Entry organiser, writer, biographer, celebrant, funeral director etc):
Name and contribution:
Name and contribution:
Name and contribution:
Name and contribution:
Notes and/or message:
---------
Type of Credit Card:
16 digit Number of Credit Card:
4 digit expiry date of Credit Card:
(Please note that giving a credit card number has the same element of risk as giving out the number over the phone. If you feel more comfortable, fax these details to the number below.)
Amount authorised:
- - - - - - - -
(For photo details please see Style and Pricing
1000-2000 words as prepared (Paste in here):



click on button to SEND

Please send the information listed above by pressing the SUBMIT button just above, or by a direct email to dallym@netspace.net.au

OR POST TO: A Personal History
9/168 Lennox St,
Richmond Vic 3121 Australia.
Phone: 61-3-9428 9926 (03 9428 9926)
Fax: 61-3-9421 3399 (03 9421 3399).
or email to:
dallym@netspace.net.au
Home Page    List of Names    How to make/change an entry    Style and Pricing

(C) Dally Messenger III, July 8, 2000

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