TEACHING ARTIST ROSTER FOR THE CENTRAL CAROLINAS APPLICATION FORM

Please check appropriate category:  
 Teaching Artist in the Schools          Teaching Artist in the Community              Both 

I.  APPLICANT INFORMATION

Name of Group or Name of Artist (Mr/Ms):

Mailing Address (for correspondence/payment):

City:   State: Zip Code:

Area Code/Phone Day:    Area Code/Phone Evening: 

Area Code/Fax Number:    Email: 

Payment for Services Should be Made to (check one):  Name listed above  Other (list below) 

Name:

Address:

City:   State: Zip Code:
(If checks are to be made out to several individuals, list each name, address and tax info separately and attach to this application.)

ID number(s) to be used on 1099 Report forms to the Internal Revenue Service.  Provide only the information to be used for Internal Revenue Service Report forms.
Social Security #  OR

Federal Tax ID #

II.  AGENT INFORMATION

Contact Person:  Title:

Mailing Address:

City:   State: Zip Code:

Area Code/Phone Day:    Area Code/Phone Evening: 

Area Code/Fax Number:    Email: 

Email #2:

III.  DISCIPLINE AND PROGRAMS

1. Check all of the items which best describe the area of work (discipline):
   Dance  Literary Arts  Music  Storytelling  Theatre  Visual Arts
   
   
2. Check any program(s) you will be offering:   Performance    Residency    Workshop

Is this program available for community centers, recreation departments, libraries, other public venues? 

Additional community program(s):    Exhibition    Mini-camp / class