APPLICATION FORM TO ATTACH TO THE DOSSIER SEND IN A SEALED ENVELOPE WITHIN DECEMBER 18TH 2017 TO: (date as postmark) Premio Arte Laguna Via Roma, 29/A - 31021 Mogliano V.to (TV)
APPLICATION FORM TO PARTICIPATE IN THE 12TH INTERNATIONAL ART PRIZE ARTE LAGUNA Painting Virtual Art
Sculpture and Installation Digital Graphic
Photographic Art Land Art
Video Art
Urban Art
Name
Attach:
Surname
1. Biography 2. Photo of each artwork / Dvd (max 2 Gb) 3. Payment of the application fee of:
Place and Date of birth Address Phone/Mobile
Performance
e55 (1 artwork)
e105 (2 artworks)
e155 (3 artworks)
e205 (4 artworks)
for artist Under 25:
E-Mail
e50 (1 artwork)
e95 (2 artworks)
Web site
e140 (3 artworks)
e185 (4 artworks)
Artwork 1* Title and Year
payed on (date) to Associazione Culturale MoCA with the reason of “Prize 17.18” through:
Artwork 2*
Bank Transfer Banca Popolare dell'Emilia Romagna - BIC: BPMOIT22XXX IBAN: IT 68 N 05387 61800 000002469464 Credit Card on artelagunaprize.com
Title and Year
MoneyGram to Laura Gallon - Mogliano V.To (TV) Italy How did you hear about the Prize?
Artwork 3* Title and Year
Artwork 4* Title and Year
I accept: 1. All rules of the regulation published on www.artelagunaprize.com 2. To give the Cultural Association MoCA the right of replication of the works and texts for the realization of the Catalogue, the Archive of entries, the Publication of the artworks in the website of the prize and other forms of communication and activities of the organization. 3. To give the Cultural Association MoCA the authorization to the treatment of the personal data according to the law on the privacy (Legislative Decree n°675/96 and n°196/2003).
*Write Size, Technique and Material on the back of the photography of the artwork or into the Dvd. For every additional artwork, write the same data on the back of each image. Date Signature
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