Florida Star Fiction Writers Membership Form

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Legal Name*

FirstLast
Date

MonthDayYear
Date
Pen Name (if different from Legal Name)

FirstLast
E-mail*
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PayPal ID or Business Name (if different from Legal or Pen name)
Phone Number*
Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
UnpublishedIndependently PublishedTraditionally PublishedHybrid Published (Indie & Traditional)
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Membership Fees (renewable only in January for $30.00 once the New Member fee is paid at any time during the year:)*
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New Member
January 1st through December 31st

$60.00 Quantity

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