Poetic Moments - Personalized Poems

Questionnaire for Personalized Poetry

Please complete all necessary sections of the questionnaire that pertain to your chosen poem. You will be contacted by Poetic Moments if there are questions regarding your responses.
* required fields

* Name:
* E-mail address:
* Street Address:
* City:
* State: * Zip Code:
* Daytime Phone:
Evening Phone:
Fax Number:

Best way to contact you for questions?

How do you wish to receive your draft? (check one) E-Mail U.S. Mail Fax

Occasion/Event:

If Other, please specify:

Title of Poem (optional):

Names of married/engaged couple and date of anniversary or wedding?

Location of Event:

Name of person for whom the poem is for:

Your first thoughts of the Occasion/Event:

Something special about the person/couple for whom the poem is for:

Note any special interests about the person/couple for whom the poem is for:

How does the person or couple make you feel:

What first attracted you to this special person or couple:

Any additional comments or special characteristics you would like to add or have included in your poem?

If you selected a Professional Frame, please specify:

If Specialty Color, please specify:

Please verify the above information for accuracy before proceeding to next step.