Your name:    

Email:            

Reason for Poem                             

Name of recipient/s                           

How many verses do you want the poem to be?

  4 Verses @ £20 5 Verses @ £25 6 Verses @ £30 7 Verses @ £35 Recommend based on info Speech

Is the poem to be read out or presented in printed form?

 

How did you hear about Jelli - Bean:

Google Other Search Engine Facebook Word of Mouth Returning Customer

How do you know the recipient?

Occupation of recipient?

Age of recipient?

What is the key message that you want me to get across?

If not a family member, please describe how you know each other / met:

Give details of at least 3 stories / memories that you would like included:   

Story 1                      

Story 2                      

Story 3                      

Any embarassing incidents you would like included?

Particular references you would like made i.e. Nicknames/pet's names/other family members/place names

Does the recipient have any strange / quirky habits or interesting hobbies?                                                   

Tone of ending?  i.e. Heart felt, humourous, etc                                      

Is the occasion to be celebrated with a meal, party, event of some description? If so please give details of date and location, type / size of event?

Any additional information: