Total dollar amount submitted: $______________

Name: ___________________________________________

Address: ___________________________________________

City: ___________________________________________

State: ______________________ Zip: _____________

Phone: (______)____________________________________

E-mail: ___________________________________________

Member: Yes__________ No__________

(Please do not send membership application or dues with conference registration.
Send to the Membership Chair.)

Please answer yes or no to the following questions:
   I will bring a book to sell. ............................................ Yes_____ No_____
   I am a Board member and will attend the Friday
        Board meeting (take $15 off of cost of registration.) .......... Yes_____No_____
   I want my name in the hat to read at Open Mic ........................ Yes_____No_____

Make all checks payable to “Wisconsin Regional Writers’ Association, Inc.” and mail with form to:

Jane Osypowski, Registration Chair
W972 Birchwood Drive
Campbellsport, WI 53010

If you have questions regarding registration, call Jane at (920)533-3044
or e-mail her at registration@wrwa.net.