Michigan Authors and Illustrators Questionnaire

Please fill out this questionnaire to be considered for entry in the Michigan Authors and Illustrators database, which is sponsored by the Michigan Association for Media in Education , the Michigan Center for the Book and the Library of Michigan .

1. First, middle (or initial), and last name.
2. Mailing address, phone, email and/or web site address. (Indicate if any contact information should be excluded from the database.)
3. Month, day and year of birth.
4. City and state of birth.
5. Father and mother's first, middle (or initial), and last name.
6. Spouse's name.
7. Children's names, beginning with the oldest.
8. Why do you write and to what do you attribute your success?
9. May inquiries be sent to you about doing workshops, readings or presentations?
10. List your military record, if you were in the service.
11. List your career history, in brief, beginning with your current position.
12. List the colleges you attended, your degrees, and the dates of the degrees.
13. List your published books or works and for each item: the publisher, the dates of publication, and the genre (i.e. children, non-fiction, poetry, etc.).
14. List any awards won by you or your work.
15. In what biographical books have you been included?
16. List any organizations to which you belong related to your writing.
17. Send a photo and book jackets for possible inclusion in the database. The author assumes responsibility for copyright permissions. (We will be unable to return any materials sent in.)
18. Please add any names and addresses of other authors who live in Michigan or who write about Michigan to be invited to complete questionnaires.

Please print this form and sign the release section below. List your answers on another sheet of paper in order by question number. Leave any questions you prefer not to answer blank. If you have any questions, you can contact MAME at miaieditor@excite.com.

Please send the form and any additional materials such as photos, book jackets or books to:

Michigan Authors and Illustrators Database Editor
c/o Michigan Association for Media in Education
1407 Rensen Street, Suite 3
Lansing, MI 48910

Submission of this questionnaire by the nominee constitutes permission for the Michigan Association for Media in Education (MAME) to publish the information in print, electronic, or other form. The editors reserve the right to select material consistent with style, standards, and space limitations. In the event of errors in publication, it will be the sole responsibility of MAME to correct the errors in a timely manner. Such correction is in lieu of any other remedy. MAME, the Michigan Center for the Book, and the Library of Michigan expressly disclaim all other liability for loss or incidental or consequential damage arising from negligence, contract, or any other cause to any party for errors in publishing.

Date____________________ Signature__________________________________