Key West Art & Historical Society Loan Agreement

Please fill out this form and fax it to: 295-6649

Lender:___________________________________
Address:__________________________________
E-mail:____________________________________
Telephone:_________________Fax:_____________
Contact:________________________________
Exhibition: 6th Annual Women’s Show 2005
Loan Dates:____________________________

Object

Artist/Maker:____________________________
Title:__________________________________
Medium:_______________________________
Dimensions:________Hx________Wx______Dx_______
Description:______________________________________
___________________________________________________________
Insurance Value: $___________________
Permission to photograph for publicity/publication: ___yes ___no
Photo/Label Credit:____________________________

Acknowledgment of Receipt and Conditions

Date Received by Key West Art & Historical Society:_________
____________________KWAHS Curator ______________________Lender
Date Returned by Key West Art & Historical Society:__________
____________________KWAHS Curator ______________________Lender