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).

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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