Print this page. Make three copies for each book entered.
AWARDS ENTRY FORM 
DEADLINE FOR SUBMISSION: January 5, 2019
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. Note: We need author contact information to communicate with winners.

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 (Adult)

CHILDREN'S FICTION

ADULT NONFICTION

BIOGRAPHY and MEMOIRS (Adult)

CHILDREN'S NONFICTION

I nominate the above work for a Society of Midland Authors Award. 
(An author may nominate their 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: