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Your Name

Your Address

City, State/Province

Zip/Postal Code     Country

Your Telephone Number

Your E-mail Address

Shipping Address (if different from above)

Occasion (Birthday, etc.)

This poem is for (Wife, Husband, Friend, etc.)

Poem should be: Funny Sentimental Serious Other

Other pertinent information (Age, Features, Special Anecdotes, etc.)

Today's date

Date poem needed by

Please choose a pre-penned poem for me ($7.95 + s/h).

Please create a poem especially for me (from $29.95 + s/h).

Method of Payment: Check   MasterCard   Visa

Account Number   Exp. Date

Signature

We're sorry, but we are unable to accept online forms at this time. Please print this form, and send to us via fax or mail, or call us toll-free at 800-832-0980.

RhymeNiks.com
P.O. Box 449

Clarksburg, NJ 08510

Fax: 732-294-0330

Phone: 800-832-0980 (toll-free)
or 732-462-3522

Email: fran@rhymeniks.com

 
 

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