Bentonsport Art Show

oct. 11 & 12, 2008

Name:____________________________________________________________________

Address:___________________________________________________________________

City:___________________________________________________State:_______________

Zip Code:_____________________ Area Code/Phone #:_____________________________

Medium:___________________________________________________________________

Social Security #:_______________________________

IA Tax ID:__________________________ If you do not have a sales permit, a temporary permit will be given to you.

Your signature below indicates that you agree that the sponsoring organizations will not be responsible for any accident or damage to you or your exhibit and that all your entries are from your originals.

Signature:______________________________________________________________________