a) Please type or print.

b) Include samples of your poetry, four pages maximum.

c) Enclose a $25 non-refundable application reading fee and a stamped self-addressed envelope.

Name: _________________________________________________________________________________

Signature: _______________________________________________________________________________

Address: ________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

Telephone: _________________________________

Fax: ______________________________________

Emergency Contact: ____________________________________________________________________________

Valid Passport #: ____________________________

Country:_______________________________________

Date of Birth: _______________________________

Gender: _________________________________________

Have you ever traveled to Mexico? ______________

When?__________________________________________

Occupation: ________________________________

Education:_______________________________________

_______________________________________________

Publications: ________________________________________________________________________

Additional Workshops:

Clement:____________

How did you hear about The San Miguel Poetry Week?________________________________________________

______________________________________________________________________________________________

FEES: Due upon acceptance

Please make checks payable to: The San Miguel Poetry Week

Registration fee

$200.00

Tuition

$475.00

Additional Clement Workshop

$50.00

For further information:

U.S.A.
The San Miguel Poetry Week
P.O. Box 171, Cooper Station
New York, NY 10276
phone: (212) 254-5157

Mexico
The San Miguel Poetry Week
Tulipan 359, Col. el Toro
Mexico 10610, D.F., Mexico
info@sanmiguelpoetry.com

Based on the judgement of the Directors, The San Miguel Poetry Week reserves the right to request the dismissal of a participant if he or she is disruptive to the program. In the event that the course must be suspended due to unforeseen circumstances, the registration fee and tuition will be refunded.