Membership Application

Title (Select one):
MrMrsMsDrNone
First Name*:

Middle Name:

Last Name*:

Suffix (Select one):
Jr.Sr.IIINone
Phone*:

E-mail*:

Address Line1*:

Address Line2:

City*:

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Genre*: Check all that apply
Non-fictionNovelShort FictionPoetryScreenplayOther
Has your work been published within the last ten years?*
YesNo
Are you a salaried writer or do you work in a literary-related profession?*
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Please use copy/paste to input a writing sample of approximately 1000 words below*: