Tentative Membership Form

Name

Pseudonym, if applicable:

Choose one, if applicable:
Published in RomancePublished in OtherPlan to Publish in the Future

Author Website, if applicable:

Address

Member's Email

Email You Plan to Use on Groups.io

Name You Plan to Use on Groups.io

Phone Number INSIDE the United States or Canada

Phone Number OUTSIDE the United States or Canada

Emergency Contact Information