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Please fill out the form below and attach a writing sample of up to ten pages along with your $150 deposit to secure your place in Lisbon next July!

Application Form

First Name*
Last Name*
Gender (You may choose not to answer this.)
Date of Birth* Enter the date in this format: MM/DD/YYYY.
Biography Optional: Share a little biographical information to fill out your member profile.
Program Affiliation

Please indicate if you are affiliated with any of these programs.
Website Optional: If you have a personal website, we will display this on your member profile.
Profession Optional: What do you do for a living? We will display this on your member profile.
Have you attended Disquiet in the past? 2011 2012 2013 2014 Check all years that apply.

How to Reach You

Please enter contact information where you can be reached through July 2014.

E-mail* (We will not publicly display any contact information.)
Street Address*
City*
State / Province / Region*
Zip / Postal Code
Country*
Country of Citizenship*
Primary Phone Number*
Secondary Phone Number
Twitter Optional: Enter your Twitter handle, without the @ sign, to display on your member profile.
Facebook Optional: Enter the URL to your Facebook to display on your member profile. (It usually looks like this: https://www.facebook.com/fernando.pessoa.himself.)
LinkedIn Optional: Enter the URL to your LinkedIn to display on your member profile.

Emergency Contact

Contact Name*
Relationship to You
Email*
Street Address*
City*
State / Province / Region*
Zip / Postal Code
Country*
Phone Number*

Workshops

Core Workshop Selection*
Select the workshop that best suits your experience level:*
If you have a preferred author to workshop with, please state his/her name here:
Additional Afternoon Workshops*

Housing

Housing*

Please see our suggestions for excellent and affordable housing options.
While Disquiet cannot guarantee that you will receive the accommodation that you select, which type of accommodation would most interest you?
Requested Roommate

Prepare a writing sample of no more than ten pages of prose or three poems.* Save as .doc, .docx, .pdf or .rtf (less than 2 MB).
Notes & Special Requests Please enter here any notes or special requests you would like the staff of the ILP to take into account in considering your application.

You’re now ready to pay the $150 application deposit. Your deposit is fully refundable in the event you are not admitted to the program, the program is cancelled, or you withdraw by the withdrawal deadline of March 15 of the program year.

Click the “Pay Now” button and complete the transaction at Paypal. After you have received confirmation of payment from Paypal, please paste your PayPal receipt number or the entire confirmation email into the Paypal receipt field so we can confirm payment.

Then hit the “Submit” button to submit your finished application.

PayPal

PayPal Receipt (You can still send your application without the receipt.)
Feature me in the public alumni directory! By joining Disquiet you have the opportunity to be featured in our Alumni Directory.

(Your deposit is fully refundable in the event you are not admitted to the program, the program is cancelled, or you withdraw by the withdrawal deadline of March 15 of the program year.)

To apply to the ILP Lisbon program by regular mail please send the following to the address below:

a printout of the completed online application
a writing sample of no more than ten pages of prose or three poems
a check made out to “Dzanc Books” for the $150 application deposit.

Dzanc Books
ILP Application
610 S. Pleasant St.
Amherst, MA 01002
USA

You will be contacted within two weeks of receipt of your application.