APPLICATION FORM TO ATTACH TO THE DOSSIER SEND IN A SEALED ENVELOPE WITHIN DECEMBER 18TH 2017 TO: (date as postmark) Premio Arte Laguna Via Roma, 29/A - 31021 Mogliano V.to (TV)

APPLICATION FORM TO PARTICIPATE IN THE 12TH INTERNATIONAL ART PRIZE ARTE LAGUNA Painting Virtual Art

Sculpture and Installation Digital Graphic

Photographic Art Land Art

Video Art

Urban Art

Name

Attach:

Surname

1. Biography 2. Photo of each artwork / Dvd (max 2 Gb) 3. Payment of the application fee of:

Place and Date of birth Address Phone/Mobile

Performance

e55 (1 artwork)

e105 (2 artworks)

e155 (3 artworks)

e205 (4 artworks)

for artist Under 25:

E-Mail

e50 (1 artwork)

e95 (2 artworks)

Web site

e140 (3 artworks)

e185 (4 artworks)

Artwork 1* Title and Year

payed on (date) to Associazione Culturale MoCA with the reason of “Prize 17.18” through:

Artwork 2*

Bank Transfer Banca Popolare dell'Emilia Romagna - BIC: BPMOIT22XXX IBAN: IT 68 N 05387 61800 000002469464 Credit Card on artelagunaprize.com

Title and Year

MoneyGram to Laura Gallon - Mogliano V.To (TV) Italy How did you hear about the Prize?

Artwork 3* Title and Year

Artwork 4* Title and Year

I accept: 1. All rules of the regulation published on www.artelagunaprize.com 2. To give the Cultural Association MoCA the right of replication of the works and texts for the realization of the Catalogue, the Archive of entries, the Publication of the artworks in the website of the prize and other forms of communication and activities of the organization. 3. To give the Cultural Association MoCA the authorization to the treatment of the personal data according to the law on the privacy (Legislative Decree n°675/96 and n°196/2003).

*Write Size, Technique and Material on the back of the photography of the artwork or into the Dvd. For every additional artwork, write the same data on the back of each image. Date Signature

INFO ARTELAGUNAPRIZE.COM +39 041 5937242 (4)