Please fill out the following information. Return the form by mail along with your chosen photos or image disk to Cyndi Bolt.

Name ________________________________________________________________
Business Name __________________________________________________________
Mailing Address ________________________________________________________
Phone Number, with area code ___________________________________________
E-mail address _________________________________________________________
Your Web site URL ______________________________________________________

Short description of your work:
* describe the medium, style or techniques used
* 25 words or less - we reserve the right to edit
* you should not repeat your name in the description as it will be listed in the address

________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Media_________________________
____ my images are enclosed

Image # 1 Name & Description ________________________________________________
Image # 2 Name & Description _______________________________________________

Mail to : Cyndi Bolt, Route 2 Box 2417, Wayne, WV 25570