June 12, 2007

White Mountain Publications: Author Questionnaire

TITLE OF BOOK (working title, if not yet finalized)

AUTHOR NAME as it will appear on book (or editor's name)

AUTHOR'S FULL NAME for CIP registration

DATE OF BIRTH: _______________________DATE OF DEATH: (if applicable)_______________

(Needed for ISBN/ National Library Registration)

ADDRESS: both mail and house address for any courier deliveries. Please include postal codes

PHONE : ( )____________________ FAX:( ) _____________________________

EMAIL: ______________________________________________________________________

Social Insurance Number/ Social Security Number (Needed for Revenue Canada)_______ ________

Citizenship (Needed for both ISBN/ National Library and CIP Registration)

[ ] Canadian Citizen	[ ] Landed Immigrant	[ ] Non-Canadian:

______________________________

Previous Books by author (include title, year of publication, publisher, country and language)

FIRST BOOK [ ] OR see list attached.

Periodicals in which author's work has been published (with any relevant notes on the nature of the material published):

NONE [ ] OR see list attached.

Significant Organizations of which author is a member (include major offices held, with dates of office, if applicable)

Recognized authorities on the book's subject matter whom the author believes might be willing to read proof and comment for publication.:

Author's biographical notes (for back cover, promotional material etc.)

Who do you see as the main group of persons who would be the audience for your work? ("Everyone" is NOT an answer)

Please make a note of any plans for this book you may have, including promotion.