Entry Fee :  $10.00 Canadian funds included with submission
NSF cheques result in immediate disqualification from competition

Made payable to:     Friends of Dutton - Dunwich

P.O. Box 58        Dutton,   Ontario     N0L1J0


Story Title : _____________________________________________________

Author : _____________________________________________________

Street Address : _____________________________________________________

P.O. Box : _____________________________________________________

City : ___________________________________________

 Province : _____________

E-Mail address : _____________________________________________________

Phone Number : ________________________

Word Count : _____________

I do affirm that my entry is my own previously unpublished work of fiction
and that I am a Canadian author.

I  hereby grant the Friends of Dutton-Dunwich permission to publish
any winning entry of mine along with some form of contact information
as supplied by me on the John Kenneth Galbraith Literary Award website


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signature                                                date

 Please be sure to enclose entry fee