Online Poetry Submission Form

Please complete the following form in its entirety. If you would like for us to contact you to obtain payment information, please indicate in the PAYMENT OPTIONS field below. Please note that all poems will be reviewed by PoetryOnline administrative personnel prior to broadcast on the site. WE DO NOT EDIT POEMS FOR CONTENT, WE MERELY CHECK EACH SUBMISSION TO ENSURE THAT THEY DO NOT CONTAIN OVERLY OFFENSIVE CONTENT THAT MAY NOT BE SUITABLE FOR OUR AUDIENCE. Upon submission, you acknowledge that the work you have submitted was written by the author and that each work has not been plagarized, and that PoetryOnline and its parent company are not liable for any misrepresented submissions.

First Name:
Last Name:
Age Range*: 6-16 17 & Up
*If in the 6-16 category, please designate an
adult as the contact person.

Contact:
Address:
City:
State:
Zip:
Home Phone:
Business Phone:
Email Address:
Category:
If Other, Type Category Here:

Submission for:
Web Site ($3.95 each) Print Edition ($19.95 each) Both Web & Print ($24.95 each)

I would like a Biography About Me Included
Yes No

I would like a picture* of myself included
Yes No
*You must provide the picture to poetryonline.com. Picture becomes property of PoetryOnline.com

Poem Entry:


Payment Options

OPTION 1:
PAY WITH A CREDIT CARD


Credit Card:

Card Number: Exp. Date:

IMPORTANT NOTICE: When you receive your credit card statement, the trasnaction for your poetry submission/s will be listed under "NetPassage, Inc." NetPassage, Inc. is the owner and operator of this website.

OPTION 2:
PAY WITH A CHECK

You may pay by Check or money order by clicking the printable form button below. Simply complete this form in its entirety and mail the form along with payment to the address listed on this form. Thank you.