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Personal Information
Name:
*
Dr.
Mr.
Ms.
Salutation
First Name
Middle Name
Last Name
Title:
(example: individual artist, executive director, development director, board member)
Email
*
Confirm Email
*
Phone
*
Phone
Ext.
Mobile Phone:
Organization Information
Legal Name:
*
Popular Name
*
Street Address
Street Address:
No PO boxes.
*
City:
*
California
Alabama
Alaska
Arizona
Arkansas
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington, D.C.
West Virginia
Wisconsin
Wyoming
City
State/Province
Postal Code/Zip
Mailing Address:
(if different from above)
City:
California
Alabama
Alaska
Arizona
Arkansas
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington, D.C.
West Virginia
Wisconsin
Wyoming
City
State
Postal Code/Zip
Website:
Applicant Type:
*
Individual Artist
Arts Group
Community Arts Organization
Professional Arts Organization
Non-Arts Organization
Other
Primary Arts Discipline
Primary Arts Discipline/ Activity (choose one):
*
Dance
Music
Opera / Music Theater
Theatre
Visual Arts
Media Arts
Literary / Literature
Interdisciplinary (2 or more disciplines form a single work)
Folk / Traditional Arts (traditions informally learned & transmitted)
Arts Service
Multi-disciplinary (2 or more disciplines listed above)
Non Profit Status
Non-Profit?
*
Yes
No
If No, Fiscal Sponsor:
Date Incorporated:
Federal ID:
Secondary Contact Person
Secondary Contact Person Name:
*
Title:
Phone:
*
Phone
Ext
Email:
*
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