The Poetry Form

Name of Customer: ____________________________
The poem is about (put an [x] in front of one):
a person [ ] a life event [ ]
a holiday [ ]
a pet [ ]
an occasion [ ]
other (please specify) ___________________________________________
Rhyme?

Yes [ ]

Do you want it as:

No [ ]
an e-mail attachment [ ]

hand-written, simple, on blank paper [ ]

What do you want the poem to be about? (Include any details, names, tid-bits you might want
included in the poem. If you want it to be addressed to someone, tell me what kind of person
they are. Details.)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Date ordered: __________________
Poem Number (poet use only): ______________________

------------------------------------------------------------------Keep this portion. Date ordered: _________________ Poem Number: _________________
For more information, contact Ayesha Zahid at ayesha.zahid@live.com or find her on Twitter
with the username @ayeshazahd
It usually takes 2-4 days to get back to you, if not sooner. A well-versed poem will soon be on
your way!

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