AG00003_.gif (10348 bytes)Custom Poems

DaRomancer's House of Poetry ]

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Purchase


Welcome to the Custom Poem Request Page.   Please fill out all fields so that
we can handle your request in a prompt fashion.  All fields that have
a
** next to them, are required fields.
In the Custom Poem Information field, please provide
as much information as you can.  If this is for a special event,
please include the name of the person this is for, gender information,
and somethings about their personality. Anything you think would help
out poets to have an idea what the reciepant is like.
If you are ordering this for you, please tell us about you.
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ALL INFORMATION PROVIDED ON THIS FORM
WILL BE KEPT CONFIDENTIAL.  WE DO NOT
SELL OUR EMAIL ADDRESSES NOR DO WE SELL
REAL PHYSICAL INFORMATION ABOUT OUR CUSOMERS.
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Custom Poem Information Form
** Your Name
** Address
Apt. or Suite
** City
** State
Provence
** Zip or Postal Code
** Country
** Phone Number ()
FAX Number ()

** Your Age

18 - 24 25 - 34 35 - 44
45 - 54 55 - 64 Over 65
** Gender Female Male

Email Address:
YourEmailName@yourdomain.com

Enter your Custom Poem Information here:

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