| ARTIST NAME: | _____________________ |
| TITLE: | _____________________ |
| TYPE OF OBJECT: | _____________________ |
| MEDIUM and SUPPORT: |
_____________________ |
| MEASUREMENTS: | _____________________ |
| SUBJECT: | _____________________ |
| DATE: (completed by artist) | _____________________ |
| DATE: (purchased) | _____________________ |
| INSCRIPTIONS, MARKINGS: | _____________________ |
| PROVENANCE: | _____________________ |
| CONDITION: | _____________________ |
| PURCHASE PRICE: | _____________________ |
| NAME, ADDRESS of VENDOR: | _____________________ |
| DOCUMENTATION: | _____________________ |
| REASON FOR REQUESTING: | _____________________ |
| SERVICE REQUESTED: | _____________________ |
| YOUR NAME: | _____________________ |
| YOUR PHONE NUMBER: | _____________________ |
| YOUR EMAIL: | _____________________ |
| YOUR FAX NUMBER: | _____________________ |