Space Coast Writers' Guild, Inc.

Membership Application 2011

                                                   Date:_____________________

Name:________________________________________________________________________

Street Address:______________________________________________________________

City:_________________________________________  State:______  Zip:___________

Home Phone: (    )___________________  Cell Phone: (    )____________________

Email:_______________________________  Web Site:_____________________________

Is this a renewal application?   Yes____    No____

Information above will be included in Membership directory
unless otherwise indicated here:______

Writing Interests:___________________________________________________________

Pen Name:____________________________________________________________________

Please list published credits on reverse side.

Are you interested in forming or participating in a critique group?

Indicate the manner in which you wish to server the SCWG:
(Please check one or more)

___ Board of Directors        ___ Serve as an Officer    ___ Newsletter Editor
___ Chair a Committee         ___ Contest Judge          ___ Other
___ Serve on a Committee      ___ Speakers Bureau

Committee Preferences:

___ Annual Conferences        ___ Contests               ___ Hospitality
___ Membership                ___ Public Relations       ___ Telephone/Email
___ Budget                    ___ Edit Newsletter
___ Publicity                 ___ Refreshments

Membership Dues are $35.00 per Calendar Year ($25.00 for students)
Please make check or money order payable to SCWG
Mail to: SCWG, PO Box 262, Melbourne, FL 32902-0262