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CHAPBOOK CONTEST ENTRY FORM

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Please fill in the information below and remember to check type of entry - prose/poetry.
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Contest Entry Form
*
*First Name
*Last Name
*Street Address
Street Address
*City
*Province/State
*Country
*Postal/Zip Code
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*Email
*Title(s)
* Enclosed is my original work. It has not been published, produced, submitted elsewhere in any form, or entered simultaneously in another contest. Please confirm.
*Date day/month/year
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