Questionnaire for Ordering a Poem

Please complete all sections of this form so we may provide you the best possible
service in a timely manner. Any information missing will need to be verified by phone
which delays the time to send you your poem. Thank You,

Name: 

Email:

Street Address:

City:     State: select... AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KA KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VR WA WV WI WY      Zip Code:

Day Phone:

Evening Phone:

Fax:

Best Way to Contact You: Day Phone   Email   Evening Phone

Best Way to Receive Your Draft: Day Phone   Email   Evening Phone

Occasion or Event (select one): Anniversary Birthday Love Condolences

Other:

Name of Person(s) Poem is for: 

Location of Event (if applicable): 

Your Thoughts of Event/Occasion:

Something Special About the Person(s):

Special Interests of Person(s):

How Does He/She Make You Feel?:

What Was The First Attraction to This Person:

Additional Comments: