*Name:

*Address:

City:

State:

Zip:

*Phone:

Fax:

Email:

Website:

*What is your book title:

Is your book self-published?:

Yes

No

Has your book already been released?:

Yes

No

Who is your publisher?:

Do you have other published books?:

Yes

No

What do you want from a publicist?:

Do you want to do bookstore signings?:

Yes

No

Do you want to give school presentations?:

Yes

No

Do you want to participate in book festivals?:

Yes

No

Educational conferences?:

Yes

No

Bookseller conferences?:

Yes

No

Do you have media contacts?:

Yes

No

Do you have media contacts?:

Yes

No

Do you have bookseller contacts?:

Yes

No

Do you have previously published books?:

Yes

No

Has your work been reviewed?:

Yes

No

If yes, where?:

What other kinds of author support do you need?:

Sales
Marketing
Distribution
Web Design
Graphic Design
Other

What do you write?:

Why do you write?: