UPLI Membership Application Form*
Please write your complete answers in the fields provided below:
Email Address *
Your answer
Title (i.e. Mr./Mrs./Ms./Dr.) *
Your answer
Family (Last) Name
Your answer
First (Given) Name *
Your answer
Middle Name *
Your answer
Address:
Number and Street *
Your answer
Town / City *
Your answer
State *
Your answer
Zip Code
Your answer
Country *
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Website
Your answer
Additional Information
Landline *
Your answer
Cellphone *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Place of Birth *
Your answer
Nationality *
Your answer
Educational Background *
Your answer
Membership in Literary Organization(s)
Your answer
Books / Poems (Published and Unpublished):
Your answer
Prizes, Awards, Citations for Poetry and Service to Poetry:
Your answer
Reference Books / Publications in which you may be listed:
Your answer
This form does not accept file uploads. After submitting this form, you may send samples of poetry, and a 2” x 2” photo through this email address: upli.sender@gmail.com Acceptable file formats are .DOC, .PDF and .JPG files. File size limit is 10 MB.
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