Electronic Membership Form

Name

Address

City

State

Zip

E-Mail

Website

Membership Type

Full Membership

Online Membership Only

I am	a published author a pre-published author

I write

Romance

Non-Fiction

Children's/YA

Mystery/Suspense/Thriller

Historical Fiction

Other genres I write:

My romance subgenre(s):

I am willing to speak on the following

I can arrange for the following speakers

I am an RWA member.

Yes

No

My RWA member number is

I will obtain RWA membership.

before the next meeting.

within the next 30 days.

Application is pending.