Mail to: Submissions Administrator POETRYONLINE.COM 419 North Magnolia Ave. Orlando, FL 32801

First Name: ________________________________________________________________
Last Name: ______________________________________________________________
Age Range*: (Circle which applies)    6-16    17+    
*if in the 6-16 category, please designate an adult as the contact person

Contact: _________________________________________________________________
Address: _________________________________________________________________
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Home Phone: __________________________________
Work Phone: __________________________________
How Many Works to Submit?_____________________

What kind of submission? (Please circle which apply)

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

Category: (Please circle which apply)

Love    Life     Nature    Death     Sadness    Happiness    Humor    Alternative    Other

If Other, Write Category Here
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I would like a Biography About Me Included ( YES / NO )

If yes, enter information here or attach bio sheet to form
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I would like a picture* of myself included ( YES / NO )
*You must provide the picture to poetryonline.com
(Attach to form* photos become the property of Poetry Online and will not be returned)

Enter My Work/s in the monthly contest ( YES / NO )

Please attach your poem(s) to form for submission.

Payment Options: (Circle which applies)

   Credit Card    Check    Money Order    Please Contact Me

Credit Card:________________________________________________________________
Number:___________________________________________________________________
Expiration Date:____________________

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