175 Bloor Street East 175 rue Bloor est South Tower, Suite 501, Édifice sud, bureau 501, Toronto, Ontario M4W 3R8 Toronto, Ontario M4W 3R8 Telephone (416) 314-6858 Téléphone (416) 314-6858 Fax (416) 314-6876 Télécopieur (416) 314-6876

TRILLIUM BOOK AWARD Submission Form

Please send 4 copies of all submitted titles with a completed copy of this form to the Ontario Media Development Corporation at the address below. Deadline for submission of books published between January and October 2016 is December 16, 2016 ; books published in November and December 2016 should be sent in no later than January 30 2017. Only books published in 2016 will be accepted. Publishers are encouraged to submit the books as soon as possible.

Title

Author

Price No of Pages Date of Publication

ISBN Cloth ISBN Paper

Publisher

Address

City Province Postal Code

Name of Contact Telephone No. ( ) E-mail Address

Please answer the following two questions:  Has the author has been a resident of Ontario for at least 3 of the past 5 years: Yes No  This book is currently in print, is eligible for consideration according to the Award guidelines and will be available for sale in Spring of 2017: Yes No Signature of Authorized Official Position/Title Date

Forward completed submissions with books to: Trillium Book Award/Prix Trillium Ontario Media Development Corporation 175 Bloor Street East South Tower, Suite 501 Toronto, ON M4W 3R8