Collectors Certification Form

To acquire the Certificate of Authenticity (stating the current market value) please fill in and send the form:

Collector's name:*
Address:**
Contact Person:
E-mail:**
Phone number:**
Preferred phone contact time:
Artwork type:	Painting Drawing Sculpture other
Artwork title:
Artwork size:
Artwork medium:	oil on linen oil on paper ink on linen ink on watercolor paper ink on paper bronze cold-cast bronze concrete steel steel and concrete other
Place of purchase:	Gallery Agent other
Gallery / Agent name:
Gallery / Agent address / location:
Additional notes:
(*) - required fields (**) - at least one of the fields required