Name:______________________________________________________________________________________

Address:____________________________________________________________________________________

City:_________________________________________________________________ State:______ Zip:________

Telephone:____________________________________________________________

Email:______________________________________________________________________________________

Website:____________________________________________________________________________________

I am a published ___ unpublished ___ writer.
I am interested in fiction ___ non-fiction ___ poetry ___ 
I am interested in article/short story ___ book/novel ___ length writing.

I am interested in the following genres: ______________________________________________________________

___________________________________________________________________________________________