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Poetry X Poetry Contest

The Poetry X Prize for Poetry Entry Form

BILLING INFO
(must match credit card or checking account - field for Poet's Name appears below)

First Name: Last Name:

Address:

Address:

City: State: Postal Code:

Province:

Country:

E-mail: (winning notification will be sent to this address)

Phone Number:

* required

Please select your method of Payment:

Credit Card

Credit Card Type:

Credit Card Number:

Security Code: Check here if no security code:

Expiration Date:

Electronic Check

Bank Name: Check No.

Routing Number: Account Number:

Account Type:

Identification for Checking information:

ID Type: ID Num. State

Entry Fee: $5.00
The contest entry fee will appear on your statement as "PLAGIARIST"

Poet Name:

Poem Title:

Poem Text: