Entry Form for the Academy and Archive of Autobiography Award 1st edition – 2016
The rights holder of the text submitted to A.D.N. shall complete this entry form in every box under his/her personal liability and shall send it as according to the indications given in the Regulation concerning the Award. They are not considered [acceptable] valid forms submitted by fax and [or(?)]without the original signature of the author/rights holder.
AUTHOR OF THE TEXT
Please print in capitalised letters
Last name (indicate the maiden name)
Name
Place of birth (specify also the province)
Date of birth
Titles/ degrees held
Current profession
Profession previous to retirement
Address Street/Square
Municiplaity
Province
Postal code
Phone numbers
Email address, if any
CURRICULUM note the principal stages of the life of the Author (marriage, work activity, moving etc.) – if the space is not sufficient, attach a page.
If the rightsholder of the text is a person different from the Author (as for example in case of finding works of a deceased family member), complete also the part below:
The text has been sent by (last name/name)
Relationship to the Author
Address Street/Square
Province
Postal code
Municipality
Phone numbers and email
I wish to enter the contest for the Academy and Archive of Autobiography Award 2014 ………………………………………….. ο
I wish the text to be filed WITHOUT entering the contest for the Award ………………………………. ο
Special conditions for the filing (privacy, reading permitted only in certain cases etc… )
Synopsis of the content:
TITLE OF THE WORK ____________________________________________________________
Date of the commencement and end of the story: ________________________________________________________
Places quoted (indicate in a precise manner, not in a generic way): ________________________________________
Indicate the relevant characters or historical events described: ____________________________________________
_____________________________________________________________________________________
The text has been written: to enter the AAA Award contest ο
to enter another initiative ο
under suggestion of friends and/or family members ο
other _________________________________________________________________________________
Period in which it has been written: ______________________________________________________________
How did you come to know of the Award and of the Academy and Archive of Autobiography? (if possible quote the exact source) ___________________________________________________________________________
_____________________________________________________________________________________
Description of the original manuscript (meaning the first draft hand-written by the Author (ex: notebook, scatered yellowish papers, diary/binder with black cover etc.). Indicate the place where the original manuscript is located. If the text has been typed-written from the first draft print “typed”.
Are you willing to donate the original manuscript to the AAACPS? YES ο NO ο
Has the text been elaborated from the first original draft of the Author? YES ο NO ο
By signing at the bottom of this form the Author of the text (or the righstholder, if different from the author) claims the authorship of the work for its content and the copyright law. The rightsholder authorizes AAA to divulge and publish his/her name, the name of the Author (except particular cases) and the content of the story and to publish and reproduce pieces of the work for non-commercial purposes. He/she consents that the text will be permanently filed with the Archive of diaries at the end of the selection for the Award. He/she declares also that the text submitted has never been published, nor printed in few copies, nor diffused. He/she declares to comply with the rules of the ………………. Privacy added .
Truly
________________________________
readable signature
PLEASE NOTIFY OF ANY FUTURE CHANGE OF ADDRESS