Name: __________________________________________________________________________

Address:_________________________________________________________________________

City:____________________________ State:__________________________ Zip:_____________

Phone:__________________________ Email:__________________________________________

Slide 1 __________________________________________________________________________

Description: _____________________________________________________________________

Slide 2 __________________________________________________________________________

Description: _____________________________________________________________________

Slide 3 __________________________________________________________________________

Description: _____________________________________________________________________

I understand that the Middlesex Art Guild, Inc. is not liable for loss or damage to artwork and personal injury. I will not be part of any legal action against the Middlesex Art Guild, Inc. or its personnel. My submission of the Application and slides/CDs shall constitute agreement to comply with all conditions set forth in this Prospectus. Permission to photograph and reproduce any accepted works for publicity is granted unless otherwise stated in writing.

Signature: _______________________________________________________________________