Full Name:

Address:

Telephone:

Fax:

Email:

Title of manuscript:

Length of manuscript:
(in words and pages)

Type of manuscript:
(non-fiction,novel, etc.)

Genre of manuscript:
(fantasy, literary,  etc.)

Target audience:

Fee (see fee scale on the Fees page of this website and enter the appropriate amount)

I have read and agree to be bound by the conditions 1 to 21 in the Terms and Conditions of Assessment and to forward the specified fee to Tom Flood and Flood Manuscripts.

    Yes �            No � 

I certify that this is entirely my own work.

     Yes �            No � 

Signed

Dated