Name

First Name

Last Name

Name of Business (if applicable)

Phone Number

(###)

###

####

Email Address

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Website (or online portfolio)

http://

Facebook Page or Instagram link

http://

During a typical week, approximately how many days do you think you would work in your studio?:

Artist Statement or Description of Creative Enterprise

Type of Artist or Creative Enterprise

(Ex: painter, architect, wood-worker... ect)