First Name:

Last Name:

Address:

City:

State:

Zip:

Telephone Number:

Fax Number:

E-Mail Address:

Web URL:

AGE GROUP:

Under 30

31-40

41-50

51-60

Over 60

BROOKLYN AFFILIATION (check any that apply):

Born in Brooklyn	Raised in Brooklyn
Working in Brooklyn	Living in Brooklyn

ART EDUCATION (Schools, Teachers):

PROFESSIONAL or BUSINESS BACKGROUND (Companies and Dates):

ART ORGANIZATION AFFILIATIONS (include dates):

PREVIOUS EXHIBITIONS & JURIED SHOWS, indicate Solo (S) Group (G) or Club (C):

COLLECTIONS (Public or Private):

CURRENT ACTIVITY:

Print this form, complete it and mail or faxt it to:
Ellen Hoyt, Membership Secretary, 1551 East 29^th Street, Brooklyn, NY 11229; FAX: 212-637-4949