Ausglass Member Directory Form

Ausglass Member Profile

Directory details for listing on ausglass.org
Your Name:*

First NameLast Name
Email Address:*

Confirmation Email
Do you want your email address included as a part of your directory listing?*

YesNo
Contact phone number*
Include country and/or area codes if necessary
Do you want your telephone number included as a part of your directory listing?*

YesNo
Website URL
Leave empty if not to be listed
Do you want your website address included as a part of your directory listing?*

YesNo
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Do you want your address included as a part of your directory listing?*

YesNo
List social media addresses* that you want included in your directory listing.
*URL, @, etc. addresses required)
Member/artist statement: (200 word limit)*

0/200
Upload image file*

Upload a File
NB: .jpg file only - min resolution 400x1000px - max upload size: 1MB - label file 'membername_imagetitle.jpg Cancelof
Image title*
Image credit*
In submitting this form I AGREE TO;
- Ausglass publishing and distributing the information herein in accordance with my instructions. This permission includes personal information that I have supplied and for which I have agreed to have included in my Member directory listing.
- Promotional use by Ausglass of the suppied image and image-related information.
Should be Empty:

Ausglass Member Profile