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I am a published ___ unpublished ___ writer.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: ________________________

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