| Full name: | |
| Address: | |
| City: | |
| Province: | |
| Postcode: | |
| Primary phone: | |
| Email: | |
| Areas of interest: | Fiction
Non Fiction Documentary Screenplays Poetry Other |
| Area of Expertise: | Editing
Publishing Art & Graphics Other |
| Publications: | |
| Membership Type: | Adult Senior (65+) Student |
| Membership Duration: |
One Year
Two Years |
Date: |
|
| Signature: | |