Refugee Artists: Submission Form

Fill in only the sections you want to. You can choose whether you want me to keep the information private or publish it for all to see on the Web site. See the privacy policy.

	OK to publish on Web?
Family Name:	yes	no

Given Names:	yes	no

Your email address (if you have one):	yes	no

Your Web page (if you have one):	yes	no

Country of origin:	yes	no

Location If you would rather not give your full address, please consider giving some indication of your location in the 'current location' box, e.g. 'Scotland' or 'NW5'.
Address:	OK to publish address on Web?
	yes	no

Address Line 1:
Address Line 2:
Town:
County/Region:
Post Code:

Current Location:	OK to publish location on Web?
(eg 'Scotland' or 'NW5')	yes	no


Phone Number :	OK to publish number on Web?
(include area code)	yes	no

Languages:

Language 1:
Language 2:
Language 3:
Language 4:
Language 5:

Media (click all that apply):

Painting
Sculpture
Printmaking
Ceramics
Video
Web/CD-ROM
Installation Art
Performance Art
Other (give details)

Statement as you would like it to appear on the artists' list:

Any message for Alex Rotas (please tell me if this form can be improved):


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