Artist Registry Information Form

Name:
Mailing Address:
City:
State:
Zip Code:
Phone:
Fax:
E-Mail:
Web Address:
Mailing address the same as physical address?    Yes   No
Physical Address:
City:
State:
Zip Code:
Please select your discipline(s):
Dance Literary Arts Music Theatre Visual Arts Other
Do you belong to any licensing or professional organizations?    Yes   No
Please list:
Artist Statement (75 word maximum):
You may include up to three images of your work. All files must be images in either the JPEG, GIF, PNG or TIFF format. Please limit image sizes to under 500kb each and no wider than 550 pixels.
Image 1:
Image 2:
Image 3:
I understand that information provided will be available to the public as part of Arts Monongahela's online Artist Registry.
Image Verification: (enter the text displayed in the image below Why?)