1. Gallery/Retail Store:

Owner:

City:

State:

Zip:

Phone:

Does this store have multiple locations?
Yes No

Comments about any of your nominees:

Does this store have multiple locations?
Yes No

Comments about any of your nominees:

3. Gallery/Retail Store:

Owner:

City:

State:

Zip:

Phone:

Does this store have multiple locations?
Yes No

Comments about any of your nominees:

4. Gallery/Retail Store:

Owner:

City:

State:

Zip:

Phone:

Does this store have multiple locations?
Yes No

Comments about any of your nominees:

5. Gallery/Retail Store:

Owner:

City:

State:

Zip:

Phone:

Does this store have multiple locations?
Yes No

Comments about any of your nominees:

Nominated By: (required information)
* Name:


* Phone:


* Fax:


* E-mail:


Yes, you may contact me for an interview on the above selections.

VOTING DEADLINE: JUNE 15, 2004