Use Tab and Shift+Tab to move among the fields on this form, or click on the field you want

to fill out.

Date Code Number [gallery use only]

gallery 10
submission form
For best consideration, please submit both an electronic copy of your work and a hard copy of your
work (with a copy of this form filled out). Hard copies should go to CoAS 205 or CoAS 211 or to your
professor.

Send the electronic copy of your submission to gallery.utpa@gmail.com in word format. If you only
submit an electronic copy, state, in the body of the email, that you have read the submission
guidelines and that you give us permission to publish your work in the magazine, should we accept it.
Include reliable contact information with all of your submissions.

Contact Information
Name      
Address      
City      
Zip Code      
Phone      
Email      

Submission Information
Under Genre are drop down menus from which you can select. For additional submissions, insert a
duplicate table row or use additional forms.

Genre Title
1.      

2.      

3.      

4.      

5.      

6.      

7.      

8.      

PLEASE NOTE: All original works MUST be picked up by the end of the spring
semester. You can pick them up at the office of Dr. Britt Haraway, CoAS 205.
Biographical Information for "Notes on Contributors"
Don’t be shy; your audience would like to know about you.

Name      
Academic Classification
Major      

Interests and/or concerns

     

Circumstances of your work’s genesis

     

How & when you began writing, got interested in photography, art, etc.
     

Something about you that readers will find interesting

     

I would you be interested in doing a public reading/presentation of your work.

I would you be interested in having your work published in a smaller, alternative format—i.e., a
chapbook.

I would you be interested in my work being published on a website.

The University of Texas-Pan American Consent Form
PART I:
I hereby forever release and discharge the University from any and all claims, actions and demands
arising out of, or in connection with, the use of my works submitted to gallery, including, without
limitation, any and all claims for invasion of privacy and/or libel.

I waive any right or option to inspect or approve the finished product or any headline, title, or other
copy which may be alongside such works, and I understand that written copy may be edited, and that
graphics may be cropped or altered, or may not reproduce satisfactorily.

I understand, that any publication of this work is within the sole discretion of the University, and that
it could possibly not be used at all.

This release shall inure to the benefit of the assigns, licensees, and legal representatives of the
University.

This consent and release covers first North American serial rights only; thereafter, all rights revert to
me, the undersigned.

PART II:
a. I hereby request:
 that my name not be used
 that the following pseudonym b used with my work:      
 that my name be used as 'written on the front of this form

b. I hereby represent:
 that I am over eighteen years of age
 that I have read this consent and understand its contents

I,      , state that my submission (s) to gallery have never been published elsewhere.

____________________________________________ ___/___/___
signature date