Untitled-1

 Artist Name: Last: __________________   First:_________________________

Street Address: ________________________________________

City, States, Zip Code: ____________________________

Phone: _____________________

Email: ______________________

Work Submissions:

#1 Title : ___________________________________________________________

  • Paper/Image Size: w:_____________H:_________________
  • Medium: __________________ Edition size: _____________
  • Description: __________________________________________________
  •  ___________________________________________________
  • Retail price: framed: ________________________
  • Unframed: ______________________

#2 Title: ___________________________________________________________

  • Paper/Image Size: w:_____________H:_________________
  • Medium: __________________ Edition size: _____________
  • Description: __________________________________________________
  •  ___________________________________________________
  • Retail price: framed: ________________________
  • Unframed: ______________________

 

    Gallery use:

     Date Submitted __________________ Received by:__________________

     Fee Paid: __________ __ credit card:_____ Check:______ Cash:_______