Ordered by:
Name: __________________________
Address: ________________________
City:__________________State: _____
Zip: ______
Phone: ______________ Fax: _____________
E-Mail Address:_____________________
Poem Created For: (daughter, son, mother, friend, etc.)
Name:_________________ Nickname:____________
(Where the poem will be shipped)
Address:_____________________________
City:_________________St:______Zip:_______
What's the occasion:______________________
(anniversary, birthday, friendship etc.)
Age:____
Sex: M___ F___
Physical Description - eye color, hair color, height,
etc.
______________________________________________
Special words:_________________________________
Name an event you want included:_________________
______________________________________________
Special Moment(s) you want added:________________
______________________________________________
What else would you like me to know about your special
person:________________________________________
_______________________________________________
Anniversary date:___________
Birthdate:__________________
Special date to be added: __________________
If you have anything else you would like for me to
include
about your special someone just add below:
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
____________________________________________________
Mail this form along with your payment to:
Ruth Sadi El
5328 Kelleys Mill Circle
Stone Mountain, GA 30088
If you have problems printing off this form just copy and paste order form into word document
etc., and print off. Any questions send to explosiverhymes@att.net
