Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Do you have prior teaching experience? *

Yes

No

Artistic Background Primary Medium(s): *

Drawing

Watercolor

Oil Painting

Mixed Media

Acrylic Painting

Fiber Arts

Printmaking

Ceramics - Handbuilding

Ceramics - Wheel

Other

I understand and agree that submitting this form does not automatically register me as a Holland Area Arts Council instructor, and that there may be certain qualifications I must meet, including the acceptance of established instructor policies and procedures before I may begin teaching, including a background check. By submitting this form, I attest that the information I have provided on the form is true and accurate. *

I Agree