A Moment in Time Order Form

Glenda Plocher --- PO Box 57, Paul, ID 83347 --- (208)438-2877 --- moment@pmt.org

Print out form, fill in all information and mail to the above address. You may e-mail your photo or mail it with the form. If you have any questions, please let me know.

Your name____________________________     Phone number___________________  
Mailing address for photo___________________________________________

_______________________________________________		  
E-Mail address (if available)_________________________________________________  


INFORMATION NEEDED ABOUT YOUR LOVED ONE

Name__________________________     Nickname__________________  
Date of birth__________________________     If deceased, date of death________________________  
Cause of death_________________________________     (accident, cancer, old age, etc.)
Color of Hair_________________     Eyes_______________     Favorite Color________________  
Hobbies, Special Interests_________________________________________________________  
Occupation and Recognitions_____________________________________________________  
Religious Affiliation________________     (only if it will make a difference in the poem or verse)______________________________________

______________________________________

______________________________________

Please list anything else you think is important about the loved one on the back of this form


FINISHED PROJECT

Size of photos requested (how many 8x10's, 5x7's etc.).  How many of each size do you want?
 
Signature_______________________     Date______________________  


PERMISSION TO USE PHOTO

In an effort to show people the new ideas I come up with, I would like permission to show your finished project to others. This would include showing it in person and also using it on the on my web site. If I have your permission, please sign the release below. Thank You.

I give my permission to let Glenda Plocher use this finished project in connection with the promotion of her company, A Moment in Time.

Any changes in the original finished project must be authorized by me in writing.

Signature_______________________   Date______________________  


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