Artist Submission

Artist/Donor Information

This submission is contributed for the following category/gallery (please select one)
Collectors CollectionUPwithARTistObjectWinescapeMultiplesDoor PrizeRaffle

Name (as would appear on a cheque and/or donation receipt) *

Address Line 1 *
Address Line 2
City *
Province *
Postal Code *

E-mail Address *

Home Telephone
Cellphone

Twitter
Facebook
Instagram
For Collector/Donors... Do you wish to remain anonymous?

YesNo

If No, please indicate the name(s) to be publicly recognized in association with this donation

Art Submission Info

Artist Name (as appears in program) *
Title *
Date *
Medium *
Dimensions/Image Size (Inches) - Height x Width x Depth (if applicable.)
x x

Is the work framed/display-ready?
YesNo

Dimensions/Frame Size (Inches) - Height x Width
x

Artist/Donor's Estimate of Fair Market Value *

Do you wish for a charitable tax receipt?
YesNo

(Artists only) Percentage of net proceeds artist opts to retain from sale of work (up to 50%)

Artist Bio (or Collector's commentary on artist, the work and how it came to be in your collection) (150 words max)

Artist Statement (150 words max)

For Collector Donations Only - Did you purchase this work of art within the last 3 years?
YesNo
If YES, what was the purchase price (note, if work purchased within the last three years your official donation receipt can only be for the amount paid, or the current fair market value, whichever is less)

Additional Notes/Comments