SHOT CALLER PRESS, LLC PRISON STORY CONTEST ENTRY FORM

Please complete and sign the front part of this form and then mail it along with your story to: Shot Caller Press, LLC 8316 N. Lombard # 334 Portland, Oregon 97203. Do not scratch off any information on this form otherwise your entry may be disqualified.

PERSONAL INFORMATION

FULL LEGAL NAME: __________________________________________________________________________________

PRISON ID NUMBER and HOUSING UNIT:________________________________________________________________

ADDRESS: ___________________________________________________________________________________________

_____________________________________________________________________________________________________

CITY: ________________________________________________________STATE: _____________ZIP: ________________

NAME OF PRISON HOUSED AT: ___________________________________________________________________________

STORY INFORMATION

TITLE: __________________________________________________________DATE WRITTEN (AT LEAST THE YEAR): _________________________

TITLE #2: ________________________________________________________DATE WRITTEN (AT LEAST THE YEAR): _________________________

PEN NAME (TO BE PUBLISHED UNDER): ___________________________________

I hereby certify that the above mentioned story(ies) I submitted is my original work and that all rights to the above mentioned story(ies) are mine. I am entering the story(ies) as an honest and true effort of my personal creativity and unique artistic vision, and I understand that my story(ies) may be published in an anthology of prison stories; and my own copyright is my responsibility. If my story(ies) is selected for publication in the anthology I give my consent to Shot Caller Press, LLC to publish, use, reuse, distribute, and use it/them along with my pen name in any way necessary for the publication, marketing and advertisement of the book waving any claim for compensation.

AUTHOR’S SIGNATURE: _________________________________________________DATE: _______
Form must be signed to enter the contest.

This side of the form must be filled out completely. Do not put your name or personal information on the story. Please send us a copy of your story only - we do not return originals.

CONTACT PERSON (Optional)

NAME:_____________________________________________________________________________________

ADDRESS:____________________________________________________________________________________

CITY: __________________________________________STATE: __________ZIP: ________________

EMAIL ADDRESS: ____________________________________________________________________

PHONE NUMBER: (__________) ____________- ____________________