Order Form For P.O.E.T.I.C. Passages Plaques

Name:

Address:

City/State/Zip:

Contact Telephone Number:

Email Address:

Please specify what plastic jewels (up to 3) that you would like such as ie. Stars, moons, dragonflies or
butterfiles

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(For E.P.P.)Please specify the correct spelling of name(s), personal anectdotes about the person. Please keep it
under 30 words.