Upstream Gallery Membership Application Form

Name

First Name

Last Name

Email

Website

http://

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Artistic Media

Please Tell us a bit more about yourself

have you been a member of a gallery previously? If yes, tell us a little about your experience:

What attracts you to Upstream Gallery, and what would be your main goals as a member?

Please provide a short artist statement.(not more than 500 words)

Please provide a Brief Bio/CV below

What skills, abilities or special interests can you offer in helping run our gallery?

Date

MM

DD

YYYY

Thank you very much for your interest in Upstream Gallery!