Writer's Background Info & Release

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The Fairfield Review
Writer's Background Information and Release

Note: We prefer that you use the on-line version of this form, here.

Otherwise, please print and complete the following form.

Please tell us a few words about yourself and your writing for a brief biography to accompany the on-line publication of your writing.

1.	How would you like your name to appear in the magazine? _____________________________________________________________
2.	What is your mailing address and e-mail address? (Note that we send acceptance or rejection notices via e-mail only.) _____________________________________________________________ _____________________________________________________________ _____________________________________________________________
3.	What attribution you would like for each poem, essay or story (e.g., initials or name)? _____________________________________________________________
4.	What is your current (or former) occupation? _____________________________________________________________ Are you a student? ______ If so, what is your age, the name of your school, and your grade or year of study? _____________________________________________________________
5.	When did you begin writing? (i.e., for how many years have you been writing?) _____________________________________________________________ _____________________________________________________________
6.	Why did you start writing? What was the motivation, the impetus, or the occasion? _____________________________________________________________ _____________________________________________________________ _____________________________________________________________
7.	Have you had any of your work published? If so, where? (If this magazine is your first publication, that counts!) _____________________________________________________________ _____________________________________________________________
8.	Have you won any awards, contests, or formal recognition for your writing? If so, please list. _____________________________________________________________ _____________________________________________________________
9.	Are you a member of any writing group or association? If so, which one(s)? _____________________________________________________________ _____________________________________________________________
10.	Do you have a special quote or comment you would like included (space permitting)? _____________________________________________________________
11.	Any other information we should have about your work when it is published? (e.g., copyrights, trademarks, footnotes, etc.) _____________________________________________________________ _____________________________________________________________
12.	Do we have your permission to include your work in The Fairfield Review, our on-line magazine published on the Internet's World Wide Web, and do you hereby certify that it is your original work, and hold The Fairfield Review Inc., its editors and employees harmless against any lawsuit that may result from the publication of this work? ____________________ (Yes or No?)

Signature: ________________________________	Date: ____________________
Name (please print): _________________________	Phone number: ____________
Email Address: _____________________________ Parent or Guardian Signature: _________________________________ (if under the age of 18)	Fax: ____________________ Date: ____________________

Fax this completed and signed form to The Fairfield Review
at 203-255-6139 or mail it to:
The Fairfield Review
c/o Edward Granger-Happ
544 Silver Spring Road
Fairfield, CT 06824

The Fairfield Review is published by the Fairfield Review Inc., a non-profit corporation.