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poetryforall
www.elliottelijackson.com
Frames, Note cards, and special poems order form
Please fill in all required information
Full Name _______________________________________________________
_____________________________________________
Street address, Include apartment or suite number
City ___________________ State ________________ . Zip __________
____________________________
Daytime phone (Include area code)
Mailing address if different than above email ________________________
Click here for Prices
Copies of Cacophony ______
8 X 10 Qty:_____ 4 X 6 Qty _____ Cards Sets Qty _______ Style _______ Color ______
Cacophony on CD Qty ________ Cassette Qty _________
Total Price $_______ (See below for deliver details, add applicable sales tax)
Special poem order:
Name or Names poem dedicated to ________________________ Occasion __________
Qty ____
(please give some details so Mr. Jackson can create that special poem)
Limit two Sentences
________________________________________________________________________
________________________________________________________________
Send Money order only, no cash to: PO. Box 271 Prospect Heights, IL. 60070-9998
Method Of Payment
Visa ___ MC ___
Account # ________________________ Exp Date ____ ____
Month Year
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