CARLOS PALANCA MEMORIAL AWARDS FOR LITERATURE 2013 OFFICIAL ENTRY FORM (Please accomplish one form per

entry)

Entry No.
(to be accomplished by CPF staff)

TITLE OF ENTRY CATEGORY DIVISION For Published Entries

: : : : Date of Publication Publisher Publication Date of Production Producer Venue of Production : : : : ________________________________________________________________ : :

For Produced Entries

AUTHORS NAME
Date of Birth (Day Month Year)

:
Place of Birth Age M Gender F Civil Status

In the event of a winning Entry, please indicate if you consent to its automatic posting on the CPMA Website to be available for downloading by the public for free. CONTACT INFORMATION : ADDRESS LANDLINE MOBILE NO. FAX NO. EMAIL : : : : : HOME

Yes

No

WORK/BUSINESS

Authors Printed Name For first-time participants, please indicate how you learned of the Palanca Awards: (NOTE: If the participant is a minor, the following should be accomplished by the parent or legal guardian.) PARENTAL CONSENT (For contestants who are minors.)

Authors Signature

I, the undersigned parent and/or legal guardian of _______________________________________, hereby submit the Entry, and execute this Official Entry Form on his/her behalf. _________________________________ Printed Name and Signature (Parent/Legal Guardian) CONTEST REQUIREMENTS: 1) Official Entry Form; 2) Notarized Authorization Form (including the Parental Consent if applicable); 3) Consent (Adapted work/s), if applicable; 4) One (1) Original and three (3) extra copies of the Entry; 5) A soft copy (cd copy) of the Entry; 6) Full rsum with photo; and 7) Synopsis (attached to each Entry) [except in the Poetry, Poetry for Children, and Essay categories].

ACKNOWLEDGMENT Republic of the Philippines) ) S.S. BEFORE ME, this ____ day of _____________________, in ____________________, Philippines, personally appeared: Name Competent Evidence of Identity Date/Place of Issue/Validity Period

known to me and to me known to be the same person/s who executed the foregoing instrument and who acknowledged to me that the same is his/her/their voluntary and free act and deed. Doc. No. ____; Page No. ____; Book No. ____; Series of 2013.