Applicant's Name:

telephone number:                                           email address:

Residency Description:

Proposed Dates::

Activities Schedule (day-by-day outline):

Contact Address or E-mail for Artist or Agent:

Estimated Flat Fee for Residency (include all expenses: travel, lodging, publicity, etc.):

I have reviewed this proposal and attest that affected individuals were consulted.

_______________________________

Department Chair/Supervisor signature