Please fill in
the following form and press submit:
Name: Last Name:
City: State: Zip:
Please select CD or Cassette:
Compact Disc $99
Select Method of payment:
Certified check/Money Order
Personal check (14 days to clear)
credit card number: expiration:
You can call in your credit card number if you would like: 866-788-9552
or Fax 801-459-3337
If Paying by check or Money order please mail to: Power
Alley 1935 State Route 12 Binghamton, NY 13901
How did you find out about Custom Memories? Where you referred by someone?
Please answer the following questions. Please include as much information as
possible. This will allow for the best results. If you need more space please
fill in the extra information box.
First name of the person this is for:
Please select the style of music she/he likes:
Where did you first meet?
How did you first meet?
What is your fondest memory together?
What nicknames do you call each other?
What are some cute habits that he/she have?
What are your favorite things that you do together?
What are some of the favorite places you like to go together?
Have you ever bought her(him) something she(he) thought was special?
What are some things things you like about her(him)
Describe her(him): Hair
Where are you from?
Where is she(he) from?
What do you want the theme to be?
I love you more now than ever
Will you marry me?
Happy I just met you
Glad we are still together
Im sorry I hurt your
Wish we were back together
I wish you were mine
EXTRA INFORMATION: (anything extra you can tell us to make it more personalized)
Please allow 30 business days for delivery.
Would you like rush delivery(10 business days) for an extra $29?
No, I do not need rush delivery
Yes, I would like rush delivery