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Fields with a red asterisk (
*
) are required.
Personal Information
Name:
*
Dr.
Mr.
Ms.
Title
First
*
Middle
Last
*
Title:
Address:
*
California
City
*
State
Postal Code/Zip Code
*
Country:
United States
Canada
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
British Virgin Islands
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Ivory Coast
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Island
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russia
Rwanda
S. Georgia and S. Sandwich Isls.
Saint Kitts & Nevis
Saint Lucia
Saint Vincent and The Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
St. Helena
St. Pierre and Miquelon
Sudan
Suriname
Svalbard and Jan Mayen Islands
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
U.S. Minor Outlying Islands
Uganda
raine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands
Wallis and Futuna Islands
Western Sahara
Yemen
Serbia and Montenegro
Zaire
Zambia
Zimbabwe
Phone:
Phone
*
Ext.
Alt. Phone
Ext.
Mobile Phone
Fax:
Email:
*
Secondary Contact:
Name
Phone
Ext.
Email
District where you work or live:
1
2
3
4
5
Organization Information
Organization, Legal Name:
*
Discipline:
Arts Education
Arts Service
Dance
Literary Arts
Media Arts
Multi-Disciplinary
Music-Choral/Opera
Music-Instrumental
Presenting
Theatre
Traditional & Folk Art
Visual Arts
Address:
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington, D.C.
West Virginia
Wisconsin
Wyoming
City
*
State
Postal Code/Zip Code
*
Country:
California
Main Phone:
Main Fax:
Website:
Federal Employee Indentification Number:
*
(mmddyyyy)
Date of Incorporation
DUNS #:
Please select the appropriate Budget Size below. Budget Size is the organization’s total unrestricted revenue for the most recently completed fiscal year, less any donated or in-kind materials or services. If you are an individual artist, select N/A in this field.
Budget Size:
*
Advancement (completed year's revenue under $100,000)
Organizational Capacity (completed year's revenue bet. $100,000-$500,000)
Artistic Growth (completed year's revenue between $500,000-$1.5M)
Access (completed year's revenue over $1.5M)
N/A
Total Gross Income for the Last Completed Fiscal Year:
*
County Supervisorial District Where Office is Located:
1
2
3
4
5
District Where Most Programming Takes Place:
1
2
3
4
5
Districts Organization Serves:
District 1
District 2
District 3
District 4
District 5
Register
Los Angeles County Arts Commission
Dulles Technology Partners Inc.