Full Name: ___________________________________________________________________

Address:    ___________________________________________________________________

City:             ____________________________________    State: ______  Zip Code:__________

Country:      ____________________________________

E-mail:         __________________________________________________________________

Number Of Poems Submitted:  ____________

Total Amount Enclosed: $ _______________  ($1.00 Per Poem)
(Remember, winner gets all entry fees as prize. Our mission is non-profit!)

Method Of Payment (X):

Money Order: __________           Cash: _________
(Payable to Lacey Hatmaker)

I certify that the poem(s) enclosed for The Poet Sanctuary Excellence Award Competition is/are  my own
original work and that I am 13 years of age or older.

Signature: ___________________________________________________  Date: ___________________

Current Deadline: December 1, 2016
TPS Excellence Competition
1517 S Dakota Ave
Lakeland, FL 33803