Complete this form to register to create options.

SELLER'S LAST NAME:
SELLER'S FIRST NAME:
MIDDLE NAME OR INITIAL:
LAND LINE PHONE (IF ANY):
CELL PHONE NUMBER:
E-MAIL ADDRESS:
STREET ADDRESS LINE 1:
STREET ADDRESS LINE 2:
CITY OR TOWN2:
ZIP (POSTAL) CODE:
STATE OR PROVINCE:	Select Alabama Alaska Alberta American Samoa Arizona Arkansas British Columbia California Canada Colorado Connecticut Delaware District of Columbia Florida Foreign Country Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Marshall Islands Maryland Massachusetts Mexico Michigan Micronesia Military(AA) Military(AE) Military(AP) Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland Newfoundland/Labrador North Carolina North Dakota N. Mariana Islands Northwest Territories Nova Scotia Nunavut Ohio Oklahoma Ontario Oregon Palau Pennsylvania Prince Edward Island Puerto Rico Quebec (PQ) Quebec (QC) Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas U.S. Virgin Islands Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Yukon
COUNTRY:
ALTERNATIVE / LONG-TERM CONTACT (LTC) INFO This section is necessary due to the long-term nature of the contract under which you are selling your work. Securitized Arts may have to track down an artist or owner many years after a sale. Thus, the long-term contact person should be someone (WHO IS NOT THE ARTIST OR SELLER) with a settled lifestyle who will always know where the work is. (A parent is a good example of someone to use here.)
LTC LAST NAME:
LTC FIRST NAME:
LTC MIDDLE NAME OR INITIAL:
LTC PREFERRED LAND LINE PHONE:
LTC CELL PHONE NUMBER:
LTC PREFERRED E-MAIL ADDRESS:
LTC ADDRESS LINE 1:
LTC ADDRESS LINE 2:
LTC CITY OR TOWN2:
LTC STATE OR PROVINCE:	Select Alabama Alaska Alberta American Samoa Arizona Arkansas British Columbia California Canada Colorado Connecticut Delaware District of Columbia Florida Foreign Country Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Marshall Islands Maryland Massachusetts Mexico Michigan Micronesia Military(AA) Military(AE) Military(AP) Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland Newfoundland/Labrador North Carolina North Dakota N Mariana Islands Northwest Territories Nova Scotia Nunavut Ohio Oklahoma Ontario Oregon Palau Pennsylvania Prince Edward Island Puerto Rico Quebec (PQ) Quebec (QC) Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas US Virgin Islands Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Yukon
LTC COUNTRY:
SOCIAL SECURITY NUMBER*:
Submit Only If Secure Site Icon (Padlock) Visible in Browser Tray -- Certificate held by Bluehost.com: (*Rationale: The success of the Exchange system -- its "liquidity" -- depends on our ability to locate buyers (and sellers) many years in the future. Unfortunately the Social Security number remains most reliable way to do this.
ABOUT THE SELLER (Even if the seller is the artist)
Is the Seller an Amateur Dealer?: (No/Yes) (Amateur Dealers sell fewer than 3 pieces per year by other artists.)
Is the Seller a Professional Dealer?: (No/Yes)
Does the Seller you have provenance documentation for the work for sale?: (No/Yes)

SECURITIZED ARTS . PO BOX 99402 . SAN DIEGO, CA . 92169 . (619) 341-4ART / 341-4278 . info@SecuritizedArts.com