Application Form
Surname/Family Name:
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First and Second Names:
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Address:
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Postcode:
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Country:
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Telephone:
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Email/Fax:
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Title of Poem(s):
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Entry Fee
| I enclose a Sterling cheque for: £ | |
| I enclose a Bank to Bank instruction for: £ | |
| IBAN: GB77LOYD30999070500960 | |
| Bank: Lloyds TSB plc, The Cross, Worcester, UK | |
| Secure payment in pounds sterling with Pay Pal made on line. | |
Important: insert the paypal Registration ID on your application form and send together with your poems to Anna Burland Services
Where did you see this competition advertised
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I............................................... declare that the attached poem(s) is/are my own original work And not previously published
Signed: ............................................... Date: ...............................................