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| Name: | |
| Email Address: | |
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| After Hours Phone: | |
| Do you have other manuscripts either completed or underway? | Yes
No
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| Are you prepared to help promote your book with readings, talks and media appearances? | Yes
No
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| If you have had any other books published previously, what were they and who published them? | |
| Other comments | |
| Attach Manuscript File: |
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