Print this page. Make three copies for each book entered.
 AWARDS ENTRY FORM
DEADLINE FOR SUBMISSION: February 1, 2013

Send one book and one copy of this completed form to each of the three judges in the book's category. Please type or print clearly.

Name of book:

Publisher:

Publication date:
(If publication date differs from copyright date, please explain in "Comments" section below.)

Author:

Author's address:

   

Author's email address:

Category of entry (circle one). Entries improperly categorized will be disqualified.

ADULT FICTION

POETRY

CHILDREN'S FICTION

ADULT NONFICTION

BIOGRAPHY

CHILDREN'S NONFICTION

I nominate the above work for a Society of Midland Authors Award.
(An author may nominate his own work.)

Your name:

Signature:

Company and Business title:

Telephone and/or email address:

Address:

If the author is not currently a resident of Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota or Wisconsin, please explain the author's connection to this region:



Comments: