Contestant Application Form for Short Story Competition

The National Society of Arts and Letters
Washington DC Chapter


CONTESTANT APPLICATION FORM
SHORT STORY COMPETITION

DEADLINE FOR SUBMISSIONS: POSTMARKED BY FEB. 8, 2010
Please print in black ink or type. Complete all three pages.

Name __________________________________________________________________
First Middle Last

Current Street/Apt. Address ________________________________________________

City ____________________________ State _______________ Zip _______________

Email _____________________ Telephone ( )___________ Fax ( ) ___________

Age _________ Date of birth ____________

U.S. Citizen? Yes ______ No ______ If Naturalized Citizen, give date ____________

Social Security number__________________(All monetary awards are taxable by the IRS.)

Address where I can always be reached:

C/O Name _____________________________ Telephone ( ) _________________

Address ________________________________ Email _________________________

City ______________________________ State _____________ Zip _____________
Application continues on next page.


Titles of the stories I am submitting:

1. ____________________________________________________ Word Count _______

2. ____________________________________________________ Word Count _______

Background Information:

Schools Locations Degrees Dates

___________________ ___________________ ______________ _______________

___________________ ___________________ ______________ _______________

___________________ ___________________ ______________ _______________


Honors, awards, publications (Feel free to add additional pages or substitute your CV or resume.)
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Newspapers/addresses (physical & electronic) to which publicity should be sent if I win an award
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Internet Release: My name and photograph may be used on the NSAL website _______________


NOTARIZED DECLARATION OF RESPONSIBILITY

I certify that the information contained in this application is true and complete and I agree to conform to the rules and regulations of the competition. I further certify that I am not under professional management and that the stories I have submitted are my original work and not yet published or accepted for publication by a mainstream press or a first tier independent publisher. If I win the Chapter competition, I agree to attend the Washington Chapter’s May 2010 meeting and to represent the chapter at the National Competition May 20-23, 2010 in Clearwater,
Florida. If I am one of the top three national winners, I will read from one of my entries as part of the Awards Banquet program on the evening of May 22, 2010.

Signature of contestant _______________________________ Date ____________


For Notary Use:

STATE OF _______________________ NOTARY SEAL


COUNTY OF _____________________


Subscribed and sworn to before me on this

______day of ____________, 2010

My commission expires on _____________________


COMPLETED APPLICATION PACKET SHOULD INCLUDE:

 Original manuscripts of two short stories with your name at the top placed in one 9 x 12” envelope with the completed 3-page application form attached to the envelope.

 Four additional copies of the manuscripts with word count of story but no name or other identifying information, placed in four 9 x 12” envelopes. Recheck Manuscript Requirements for format.

 Photocopy of a legal document verifying your date of birth and citizenship (birth certificate, passport or naturalization papers).

 CD with a high resolution JPEG head shot of yourself suitable for publicity purposes.


SEND COMPLETED APPLICATION PACKET TO:

NSAL Washington Chapter
Alicia Klaffky
4101 Dresden Street Telephone: 301-946-5651
Kensington, MD 20895 Email: klaffkys@yahoo.com

FOR FURTHER INFORMATION: Washington Chapter web site: www.nsal-dc.org
NSAL national web site: www.arts-nsal.org