The William Fletcher Residency in Rome

APPLICATION FORM for 2011

A. Contact details Complete all fields

1.  full name: Mr/Ms ........... .......... .......... .......... .......... ..........

2.  address: ........... .......... .......... .......... .......... .......... ..........

........... .......... .......... .......... .......... .......... postcode.........

3.  phone: Home & mobile........... .......... .......... .......... ..........

4.  date of birth: ........... 5.  e-address: ........... .......... ..........

B. Eligibility Complete appropriate fields in at least two of (a), (b), (c)

(a) Training (all fields)

tertiary institution: ........... .......... .......... .......... .......... ..........

qualification awarded:  ........... .......... .......... year awarded: ..........

(b) Exhibition (all fields) If you wish to indicate others, use optional CV.

gallery: ........... .......... .......... .........month & year: .......... ..........

Solo or group (give details): ........... .......... .......... .......... ..........

(c) Commission/grant/prize (complete at least one field, with year)

commission: ........... .......... .......... .......... .......... year: ..........

grant........... .......... .......... .......... .......... .......... year:..........

prize: ........... .......... .......... .......... .......... ......... year:..........

C Application and declaration
I hereby apply for the 2011 William Fletcher Residency in Rome.

I declare:
1) that I am an Australian citizen presently resident in NSW or ACT,
2) that I am applying in the field/s of painting, drawing, sculpture (underline or circle);
3) that I enclose a PowerPoint presentation containing 10 examples of my own work;
4) that I enclose two or more professional references;
5) that all the information I have supplied is correct.

signature: ........... .......... .......... .........    date: .......... ..........

witness (JP): ........... .......... .......... ..........   date: .......... ..........