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The Moth Poetry Prize Entry Form 2022 Name: .................................................................................................... Address: .................................................................................................... Email: .................................................................................................... Tel: .................................................................................................... Number of poems: .................................................................................................... Names of poems: .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... .................................................................................................... Please do not include these details on the pages with the poems.
Method of payment: Cheque or cash (15 per poem) □ Cash or postal order (Ireland/UK only) (15 per poem) □ Current issue of The Moth (Ireland/UK) 7 □ Current issue of The Moth (Europe) 8 □ Current issue of The Moth (ROW) 10 □ Back issue of The Moth (Ireland/UK) 5 □
Gift bundle of 5 back issues (Ireland/UK) 20 □ Gift bundle of 5 back issues (Europe) 28 □ Gift bundle of 5 back issues (ROW) 32 □ Total ............................... The Moth Ardan Grange Milltown Belturbet Co. Cavan Ireland
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