Date:_____________________         

Name:_________________________________________________________________________________

Address:_______________________________________________________________________________

City:______________________________________________ State:________________ Zip:____________

Telephone: _____________________________________________________________________________

RWA Number: __________________________________________________________________________
(To join WisRWA, you must be a member of RWA. Membership will be verified.)

Email Address: __________________________________________________________________________

______ Please add me to the WisRWA e-mail list
______ It is okay to publish my e-mail address for member use only
______ Please don't publish my e-mail address

I am located in, or closest to, the following area:
______ Chippewa Falls Area          ______ Milwaukee
______ Greater Green Bay Area     ______ Wausau Area
______ Madison                             ______ Other

I am published in book length fiction: _____ Yes _____ No

Area of interest (i.e.: romantic suspense, single title, etc.):
___________________________________________________________________________

Publisher: ____________________________________________________________________

I am published in the other following areas: ___________________________________________

Pseudonym: __________________________________________________________________

Membership dues are $25.00.
Dues paid between August 1, 2007 and January 31, 2008 will be eligible for renewal on August 1, 2008.
Dues paid between February 1, 2008 and July 31, 2008 will be eligible for renewal on August 1, 2009.

Please make check payable to WisRWA.

Mail payment and form to:
Jamie Kersten
520 Adams St.
Wausau, WI 54403

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