Artist Form for Birdhouse Submissions

Your Birdhouse Will Help Provide
a Safe Haven for Troubled Teens!
Applications and Birdhouses due by January 22, 2012

(email for drop-off information)

First Name:

Last Name:

Address:

City:

State:

Zip:

Email:

Website:

Home Phone Number:

Work Phone Number:

Mobile Phone Number:

Please name your birdhouse:

Can this birdhouse be used outdoors?:
Yes
No

Please provide brief description of your birdhouse:

What is your current profession?:

What motivated you to build a birdhouse?:

How did you become interested in your craft?:

Please describe any (a) awards you've received, (b) where your work has been exhibited and (c) where people can see your work: