Certa's Author Form Please answer the following questions to the best of your ability so that we have all of the information we need to copyright and publish your book. What is the author's full legal name?(*) Invalid Input What is the name appearing on the cover and/or title page?(*) Invalid Input Date of Birth(*) Invalid Input Citizen of Which Country?(*) Invalid Input Mailing Address:(*) Invalid Input Email Address:(*) Invalid Input Phone Number:(*) Do Not Leave Blank - If you do not have a land-line phone, enter "none". Mobile Phone:(*) Do Not Leave Blank - If you do not have a mobile phone, enter "none". Fax Number: (If you have one) Invalid Input What is the full title of your book?(*) Invalid Input What is your book's sub-title if used? Invalid Input List authors that wrote this book. (Can list up to 3 authors. Must be as it appears on the title page.)(*) 1st Author: 2nd Author: 3rd Author: Invalid Input Were you employed or commissioned to do this work?(*) YesNo Invalid Input Desired Final Size of Your Book: Invalid Input Approximate Number of Pages: Invalid Input Year of Completion: Invalid Input Language of Text: Invalid Input If title consists of more than one physical volume, how many volumes are planned? Invalid Input This application is for which volume number? Invalid Input Has this book been published before? If so, please describe including date, ISBN, etc. Invalid Input Previous copyright registration number: Invalid Input Previous Copyright Year: Invalid Input Type of Book (e.g., historical novel, memoir, text, poetry, etc.):(*) Invalid Input Intended Audience (e.g., adults, young adults, children):(*) Invalid Input If for children, what grade level?(*) Invalid Input Subject Matter (e.g., non-fiction, fiction, self-help, poetry, etc.):(*) Invalid Input Enter up to 12 keywords or phrases a potential customer might use when searching for your book on the Internet.(*) 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10 - 11 - 12 - Invalid Input Enter a brief description or teaser for book (your sales pitch in 100 characters)(*) 0/100 Invalid Input Full Book Description (300 characters)(*) 0/300 Invalid Input Author Biography (200 characters)(*) 0/200 Invalid Input Book Dedication Invalid Input Additional Comments or Instructions Invalid Input Cover Concept Description Invalid Input Upload Cover Concept Image Invalid Input What Message Are You Trying to Project with Your Cover? Invalid Input Any Other Information that Would Be Helpful for Us to Know About Your Cover Design? Invalid Input For Security, Please Complete This Captcha(*) Invalid Input Click Here to Submit Your Author Form
