Join Outreach Mail-only Form
Outreach International Romance Writers
Membership Application Form

(Please print clearly)

Select one
____ New Member ____ Renewal

RWA® membership number (Required for OIRW membership) __________

Date: ________________________________

Name____________________________________________________________

Pseudonym(s)____________________________________________________

Mailing Address_________________________________________________

City__________________________________ State/Province___________

Zip/PC________________________________ Country__________________

Phone (days)___________________________ (eves)__________________

Fax________________________________

Email __________________________________________________________
I joined Outreach because: (Circle all that apply)

No local chapters nearby. Recommended by OIRW member.
I am interested in services provided. Visited the web site.
Other: _________________________________________________________

Referred by:_______________________________________________________

Are you published? _____Yes _____No

Are you RWA PRO®? ____Yes ____No

Book-length Romance: Conventional or E-published/Audio

Novella or short-story romance

Other: ________________________________________________________
Are you a member of PAN (RWA® Published Author's Network)____Yes or ____No

How long have you belonged to RWA®?_______________ Outreach? _____________
Outreach is operated entirely by volunteers. As we add new programs and services,
we need more people to help out. Would you be willing to add your name to our list of those
who are willing to assist? _____Yes _____No

Sign me up!

My $15.00 membership fee in Outreach International is enclosed. (Check or money
order in U. S. FUNDS ONLY.) There is a $25 charge for returned unpaid checks.
Applications take 4-6 weeks to process. Thank you for your patience.

Signed: ____________________________________ Date: ____________________

Mail application form and check or money order made out to OIRW to:

Outreach International Membership Chair
c/o OIRW Treasurer
PO Box 531541
Cincinnati, OH 45253

or contact the membership chair at: memberat@oirw.net