Unpublished $5.00
Published $10.00
TOTAL: $0.00 
POEM(S) FOR SUBMISSION
Poem 1
Poem 2
(Optional)
BILLING ADDRESS
FIRST NAME  
LAST NAME  
EMAIL ADDRESS  
ADDRESS  
CITY  
STATE
  ZIP CODE  
PHONE
 -   -   
International poets: Please submit your poetry via traditional mail. Thanks!
BILLING INFORMATION
CARD NUMBER  
CARD TYPE
EXP DATE /
CSV #  
 
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