Name: _____________________________________________________________

Street Address: ______________________________________________________

City: _______________________________ State: ______ Zip: ______________

Home Phone Number: _____________________________

E-mail Address: __________________________________

Web Page/URL Address: ______________________________________________

Are you a member of RWA? ____ Yes, Membership # ______________

____ No, Please send me an RWA application

Are you currently published in any of the following areas:
____ Full Length Romance ____ Full Length Fiction

____ Non-Fiction ____ Other ____________________

____ I have enclosed a copy of my backlist and upcoming releases

____ Pseudonym(s): ____________________________________________

What would you like most from this organization? _________________________

__________________________________________________________________

Would you be interested in volunteering? ____ Yes

Please send payment in the amount of $30.00 to:

Capital Region RWA
PO Box 314
East Greenbush, New York 12061

Make checks payable to: CAPITAL REGION ROMANCE WRITERS