​POEM/SHORT STORY ENTRY FORM



Submissions for Break The Cycle Volume IV are open. The book will be published April 2018. All submissions must include your name (plus pen name if you use one), address, phone number, email address, and signature. There is no charge to enter your poem or short story. Limit five poems/short stories submissions. There is no monetary compensation for works published, but authors will be given an opportunity to promote their website, networks, and contact info. along with being able to purchase the volume they contribute to at cost. Book may be published in a variety of formats including physical, electronic and audio. Proceeds will be donated to local and national organizations that help neglected and abused children. You maintain the copyright of your poem. Please complete the form below and mail it to Break The Cycle Books, 700 Race St, Jonesboro, IN 46938 or email it to contest@breakthecyclebooks.com. Please print.

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Name ______________________________________ Pen Name ______________________________________



Address ___________________________________ City/State/Zip _____________________________________

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Phone Number ___________________________ Email Address _________________________________________

 

Title of Poem/Short Story

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Bio/Other Info to publish if your submission is selected (use separate sheet if necessary)



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Signature

My signature acknowledges that I am the author of the poem or short story submitted, that I am aware that I will not receive compensation for published poem and/or short story, and that I give permission to publish my submitted work(s) in Break The Cycle, Volume III.