Name:__________________________________________________________________
                          First Name                                        MI                                     Last Name

Name in your country's character:____________________________________________

Contact Information:
Address:________________________________________________________________
City:_________________________ State:_________________ Zip code: ___________
Home phone:_________________________Work phone:_________________________

Permanent Address:_______________________________________________________
Address:________________________________________________________________
City:_________________________ State:_________________ Zip code: ___________

E-mail:_______________________________Web site:___________________________

Which educational institution that you attended do you most identify with?
________________________________________________________________________

Do you want your contact information to be posted on the Web?___________________
      If yes, which information would you like posted?_____________________________
      ____________________________________________________________________

Ethnicity: mark all relevant categories

[  ] American [  ] Caucasian [  ] Indonesian [  ] Thai [  ] Vietnamese [  ] Laotian [  ] Malaysian

[  ] Afghanistan [  ] Chinese [  ] Japanese [  ] Native American [  ] Hapa [  ] Latino [  ] Cambodian

[  ] African [  ] Filipino [  ] Korean [  ] Burmese [  ] Pacific Islander [  ] Indian [  ] Other--please specify:     _________________

Gender:_____Male _____Female
Year of birth:________Birthplace:__________________________________

Media: mark all relevant categories

[  ] Acrylic [  ] Sculpture [  ] Computer [  ] Craft [  ] Drawing [  ] Calligraphy [  ] Sound [  ] Installation [  ] Interactive [  ] Photograph [  ] Video/Film [  ] Stone [  ] Latex/Chemical

[  ] Painting [  ] Plastic [  ] Ready-made [  ] Sound [  ] Glass [  ] Folk Art [  ] Kinetic [  ] Organic Material [  ] Performance [  ] Web Based [  ] Food [  ] Light [  ] Watercolor

[  ] Print [  ] Text [  ] Wood [  ] Oil [  ] Fiber [  ] Metal [  ] Paper [  ] Stone [  ] Sumi ink [  ] Motors [  ] Projection [  ] Other, please specify:      _________________

Type: mark all relevant categories

[  ] Abstract [  ] Conceptual [  ] Functional [  ] Processional [  ] Activist [  ] Decorative [  ] Gender/Sexuality

[  ] Aesthetics [  ] Environment [  ] Identity [  ] Pop [  ] Auto-biographical [  ] Feminism [  ] Kitsch

[  ] Cartoonesque [  ] Figurative [  ] Nature [  ] Spirituality [  ] Technology [  ] Social Issues [  ] Traditional [  ] Other, please specify:      _________________

I AGREE TO HAVE MY VISUAL MATERIAL USED BY AAAC FOR EDUCATIONAL & PUBLICITY PURPOSES, INCLUSIVE OF ALL DIGITAL FORMATS.

Your signature __________________________________________________