Name_____________________________________  Birth Date_____________

    Street Address____________________________________________________

    City, State, Zip__________________________________________________

    Home Phone_________________________Work Phone_____________________

    Email Address ______________________________________________________

    National RWA Membership Number ___________________________________

    Please list any other writing organizations to which you belong:
    __________________________________________________________________

    Are you published?  Yes / No (Indicate one)

    If published, in what area or genre?______________________________

    In which genre are you writing now?_______________________________

    Have you ever taken a writing class?  Yes / No

    Please list any areas of special knowlege that you could share or
    help others with:_________________________________________________
    __________________________________________________________________

    Do you now, or have you ever, belonged to a critique group? Yes / No
    ===================================================================
    IVRWA Membership Requirements:
      1- Current membership in the National RWA
                         -AND-
      2- Annual membership dues of:
           A- $25.00 full membership *
           B- $12.00 associate membership
         * Members joining after June will pay dues of $15.00
    ===================================================================
    Please complete this form and mail with payment to:
      IVRWA Membership, % The Book Ladies,
        511 N. Main St. #103, Corona CA 92880

    Application Date:_________________ Amount Paid:___________

    Member's Signature:______________________