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Online Personalised Poem Request


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All my poems are original and personally for you.
They are not copies or randomly selected from a data base.


Please Tell me a bit about your special person, and what you would like to say to them

Just complete this form. Clicking the box to fill it in,
Click on Submit when ready to send.

 

Your name:

Email address:

Contact Name

Phone number

Fax number

Cell Phone number

Work Phone number (optional)

There is a charge of US$5 per verse,
I will email it to you within three days.

Select Credit Card:
Mastercard
Visa
American Express
Diners
Bank Card

Card Number

Expiry Date

Card Name:

Please Submit some details about your special person, and tell me what you want to say to them in your message, I will turn it into a short verse for you.

Please Supply Your Full Address

 

 


If you aren't comfortable about submitting your credit card details
over the Internet, you can fill out the form & print it out, then
Fax to (03) 434 7092 from inside New Zealand,
      + 64 3 434 7092 from anywhere else,
or Post to:
Middle Image,
17 CRD
Oamaru,
New Zealand.


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