OWNER Name: FOR INTERAL PURPOSES ONLY. Information provided will be kept in sctrict confidence. *


OWNER EMAIL: *


Address/City/State/Zip Code: *


Telephone: *


Fax:


CREDIT LINE: Indicate how the credit line should appear in any public documents. If you prefer to remain anonymous, please specify "Private Collection" and your city and state, if you wish that included. *


The Sam Francis Foundation may require a visual inspection of the work in the future, please indicate where the work is currently located: Please keep us informed if this work changes hands. *


TITLE OF WORK: (or short description if title is not known) *


ID #: (any identification number if known or on artwork)


CREATION DATE: *


MEDIUM: (oil, watercolor, gouache, ink, acrylic, etc.) *


SUPPORT: (canvas, paper, wood, board, etc.) *


PAPER/CANVAS DIMENSIONS: Please measure to the nearest 1/8", using height by width (please do not include frame or mat): *


SIGNATURE: Indicate as exactly as possible how signature, date and/or inscriptions (other markings) appear: *


Location of Signature, date and/or inscriptions: *
On Reverse Other (please describe below)

If other location, please describe:


Labels and other markings on back of work (shape, colour and markings):


CONDITION: Describe the works condition, including whether it has been relined, restored or retouched.


Is the work in original stretcher and/or framed:


PROVENANCE HISTORY: From whom did you acquire this work? It is imperative to provide provenance history in order for us to document the painting. *


Date of Acquisition:


PREVIOUS OWNERS: Please list names, addresses and dates of ownership of all other previous owners known):


EXHIBITION HISTORY:Please list in chronological order, starting with the earliest, all exhibitions in which this work was shown:


PUBLICATION HISTORY: Please list any references to this work that are included in published sources, i.e. books, magazines, catalogues, etc. Indicate the work's page and catalogue #, plus any corrections.


Existing reproduction quality photography of the work? (transparency, 35mm slide or high resolution digital) *
Yes
No

Please attach an image of the work for identification purposes. We will contact you if we need to request better photography.


By submitting this Submission Form to the Sam Francis Foundation, the owner certifies that all information provided is accurate and that no information pertaining to the artwork, its history, or ownership has been withheld. The above credit line will be the information used should the painting be reproduced in a Sam Francis publication. Submitted by: *