Name
Mailing Address (optional) 
 City, State                               Country if not U.S. 
Email Address   
If you wish to use a pseudonym, instead of your own name, for author and copyright credit enter the name here:    
My story was previously published:   Yes         No      If yes, enter year published, to be used for copyright notice:  
Mystery/Crime etc-        Other/General Fiction-        Poem-     

Publish the following email address with story/poem:   

Title of Story/Poem:  
Approximate Word Count:  

If Short Story, paste synopsis here:

If Poem, paste poem here:

I have read the Submission Guidelines and agree to the terms and conditions set forth therein for publication of my story or poem if selected for publication (check box):   Yes         No