|
2010 Backspace November 11 & 12 Agent-Author Seminar Registration Form
PLEASE TYPE OR PRINT CLEARLY - this is especially important for your email address, since all conference correspondence is by email.
PRINTING TIP: select one of the printing options using the icons at the top right.
QUESTIONS: feel free to email Backspace at
This e-mail address is being protected from spambots. You need JavaScript enabled to view it
or
This e-mail address is being protected from spambots. You need JavaScript enabled to view it
. you may also telephone Christopher Graham at 732-267-6449.
First Name _______________________________________________________________
Last Name _______________________________________________________________
Address _________________________________________________________________
City ____________________________________________________________________
State/Prov. ___________________________ Zip Code _______________
Email ___________________________________________________________________
Phone __________________________________________________________________
Genre (Choose One: Literary Fiction, Commercial Fiction, Women's Fiction, Romance, Mystery, Thriller, Young Adult, Fantasy/Sci-Fi, Non-Fiction, Memoir) ________________________________________________
Amount Enclosed (Check One):
November 11 & 12 - EARLY REGISTRATION DISCOUNT - $495: _____________
AFTER SEPTEMBER 15: - $595: ______________________________________
November 11 ONLY - EARLY REGISTRATION DISCOUNT - $275: _____________
AFTER SEPTEMBER 15: - $295: ______________________________________
November 12 ONLY - EARLY REGISTRATION DISCOUNT - $275: _____________
AFTER SEPTEMBER 15: - $295: ______________________________________
Kathleen Ortiz evening BONUS workshop - $45: _____________
Note: Checks and money orders drawn on U.S. only, please. Registrants from other countries must pay using a credit card.
Send completed registration form, along with appropriate payment to:
Backspace, LLC
P.O. Box 454
Washington, Michigan 48094
|
