Govenors Enviromental Art Challenge Entry {51756}

GOVERNOR'S ENVIRONMENTAL ART CHALLENGE ENTRY State Form 51756 (R / 7-04) Indiana Department of Environmental Management INSTRUCTIONS: 1. 2. 3. 4. Complete all lines of the entry form Sign and date the release section Entry must be received at IDEM no later than October 1 By submitting your entry you are indicating that you have read and agree to all contest rules ENTRY INFORMATION First and Last Name of Artist Address of Artist (number and street, city, state, and ZIP code) Phone Number Title for Artwork Medium or Materials Used to Construct Artwork Artist's statement explaining environmental impetus for the work (maximum of 250 words) Dimensions/Size of Artwork E-mail address RELEASE SECTION I hereby give the Indiana Department of Environmental Management (IDEM) and the Indiana Arts Commission (IAC) the right to use this entry for exhibit and display at all IDEM-hosted events including but not limited to digital reproductions, with credit given to the artist, made available through the IDEM Web site. I understand that the work may be retained by IDEM for exhibit at Indiana government offices for a period of 12 months. I hold the IAC and IDEM harmless from any and all liability that might arise out of or result from the foregoing use. Signature of Artist Printed Name Date (month, day, year) Are you at least 18 years of age? Yes Are you an Indiana resident? No No Are you a U.S. Citizen or permanent legal resident? Yes No Yes IDEM, Office of Media and Communications Services Room N1301 100 North Senate Avenue P.O. Box 6015 Indianapolis, IN 46206-6015 ahartsoc@dem.state.in.us Indiana Department of Environmental Management Indiana Government Center North 100 N. Senate Ave. Rm. N1301 Indianapolis, IN 46204 Return Completed Entries to: By Mail: By e-mail: Entries may be dropped off at: (Please call first. Contact Amy Hartsock at (317) 233-4927 between 8 a.m. and 4:30 p.m. Monday through Friday.) The contest is open to artists residing in Indiana who are U.S. citizens or permanent legal residents at least 18 years of age. American LegalNet, Inc. www.FormsWorkflow.com