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Annual Art Acquisition – Submission Strathcona County Art Gallery @ 501, #120, 501 Festival Avenue, Sherwood Park, AB T8A 4X3

Name

Phone 780-410-8585 Fax 780-410-8580

Date

Address Street and number

City/town

Contact phone number Which collection

Province

Postal code

Email address

Mayor’s Collection (donations)

Permanent Art Collection (purchase)

Youth Collection (loan)

Youth Collection (purchase)

Media (E.g. Painting, sculpture, etc.) Title of work Date created

Dimensions (cm X cm)

Price $ Statement about this art work

Biographical statement (to be displayed in part or in full with the artwork)

Consent to release information I hereby consent to the disclosure of my personal information to those who have expressed an interest in purchasing the artwork I have submitted to Gallery@501 or another related piece of artwork that I have created. I understand this consent is in effect until the purposes of this consent have been concluded or that I may revoke this consent, in writing, at any time. I also understand that if I revoke this consent it may result in future services, benefits, or the like, being discontinued.

Signature Collection and use of personal information Personal information is being collected under the authority of the Municipal Government Act (MGA) and the Freedom of Information and Protection of Privacy Act (FOIP) and is managed in accordance with the provisions of FOIP. This information will be stored as part of our registry of community artists in order to help us build a base of visual artist in the community. We will use this information in order to communicate with and promote local artists. If you have any questions about the use and collection of the information, contact the Manager, Central Services, Recreation, Parks and Culture at 780-467-2211.

For office use only Proof of residency shown

yes

no Date

Acquired

yes

no REC 27037-E

Saving this form electronically requires Adobe Reader 9.0 or newer. Once completed and printed, it can be scanned and emailed to artgallery@strathcona.ca or delivered to the address at the top of the form.


Annual Art Acquisition Form