Name Wish Poem Order Form
Please complete this form and then fax or mail it to us.
FAX (970) 669-5052 (credit card orders only) Please allow 2 - 3 weeks for delivery.		Birthday Keepsakes LLC P.O. Box 7679 Loveland, CO 80537-0679 Please allow 4 - 5 weeks for delivery. Please include check, money order or credit card information with order form.

Please tell us about your child. Make sure to use upper and lower case letters while completing this form. (example: Jane Smith, not JANE smith)
Child's First Name	(required)
	11 characters max, A~Z, hypens and spaces only
Child's Full Name	(optional)
Child's Birth Date	(optional)

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Design Choices
Size	8x10
Border Design	Bears    Birthday    Boy Poem    Boys    Dolls    Fish    Girl Poem    Girls    Meadow    Noah    Party    Sports    Stork    Toys    Toys-Blue    Toys-Pink
Frame	8X10 Blue    8x10 Oak    8x10 Pink    8x10 White (Note: The blue frame is not recommended for the Stork design and the pink frame is not recommended for the Girl Poem design.)

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Special Instructions

Gift Information

If this Poem is a gift, please tell us what you would like to say on the gift note. You have up to 3 lines and 30 characters per line.

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Ship To			Bill To
Name			Name
Address			Address
City			City
State			State
Zip			Zip
Country			Country
Email			Phone
			(in case we have questions about your order)
Would you like to receive informative Birthday Keepsakes mailings in the future? Yes No

Order Details Item Qty Price Total Framed Name Wish Poem(8x10) X $25.99 $_________ UnFramed Name Wish Poem(8x10) X $7.99 $_________ Gift Wrap X $4.95 $_________ Shipping   $_____2.99 Additional Shipping for each Framed Poem X $4.00 $_________ Subtotal   $_________ Sales Tax   CO residents add 3.7% sales tax   (0.037 x Subtotal)   $_________ Total   $_________

Payment Information I am paying by    Visa        MasterCard    American Express           Check        Money Order Credit Card Number Name on Card Expiration Date / CCV Number Signature _________________________