Collector's Form

Title of artwork:

Year:

Medium:

Dimensions:

If the work consists of more than one panel or photograph, how many parts total are in the work?

If applicable, please note if the work is signed, titled, and dated, and the location of each on the work:

From whom did you acquire the work?

Date you acquired the work:

If applicable, to whom did you sell or transfer the work?

Exhibitions and/or publications the work has appeared in:

Is a photograph of the work available?

How would you like to be credited in this publication (examples: your name; your name with city designation; “Private collection;” “Private collection” with city designation):

Name of owner:

Owner’s Address:

Phone:

Email address: