Application Form

Fill in the following items, and send the form to us to apply for entry.
Details of creator
Name

Pen name*If you choose to use one.

Creator’s nameAge
Disability type

Details of applicant (contact information) *Results will be mailed to this address.
Name

Applicant’s name
Relationship to artist[1] Artist himself/herself[3] Legal guardian[2] Person with parental responsibilities and rights (for a minor)[4] Juridical person entrusted with rights to the entered artwork

Address(If institution, etc.,
specify its name, inaddition to theaddress)

Phone/fax numbers

Phone

FaxE-mail* The creator’s/applicant’s personal information will be used for the purposes, and under the conditions, specified below.
[1] notification of the screening result and return of the work, [2] inquiry regarding this application, [3] publication of the work title and thecreator’s name in/on publicity materials issued by The Nippon Foundation DIVERSITY IN THE ARTS, related websites and exhibitions, and [4]other purposes to which the creator/applicant or his/her proxy consents. [5] Without obtaining the consent of the creator/applicant or his/her proxy,his/her personal information will not be disclosed or provided to any third parties other than entities to which we outsource specific tasks
necessary to accomplish the abovementioned

Photo of the work for entry

purposes,

unlesssuch

disclosure

andprovision are duly required under laws andAttach a photo of the work for entry here.

regulations.

*Indicate the correct orientation of the work
(top and bottom) on the back of the photo.
* If the work is a three-dimensional object, etc.,
attach a photo showing the front of the work.

■ If you wish to enter more than one work,
be sure to submit an application form foreach of the works.
■ Photocopy the completed application

Attach the photo the correct way up. If the work is taller than it is wide, attach thephoto so that the top is on the left.

form and keep it at hand.
■ The application form and the photoattached to it will not be returned.

Details of the work for entry
Year created
Title

Circle the item that applies to the work.
Type

Painting or drawing (including Illustration, Computer graphics (printed out) .etc.)
Calligraphic work/ Photo / Three-dimensional art work

Length/height

Width// Other (Specify):
Depth (If three-dimensional)

Size and weightcm

cm

Examples: acrylic and crayon on canvas, etc.

cm

WeightMaterialkg

About the creator（profile, history of creative activities, etc.）* Use a separate sheet if necessary. If using a separate sheet, do not staple the sheet to this form; simply enclose it with the form.

About the work for entry(Thoughts, feelings, etc., concerning/infused into the work; the background of its creation, etc.)* Use a separate sheet if necessary. If using a separate sheet, do not staple the sheet to this form; simply enclose it with the form.

Confirmation on the extent of publication（Please put a ✔ in the box of the item you choose.）□ I agree to have my real □ Please use my pen

Your country/region of□ Disclosename published.

residence□ Not to Disclosename for publication.

■ Application/inquiry:
Email: contest@diversity-in-the-arts.jp
The Nippon Foundation DIVERSITY IN THE ARTSInternational Communication Center for Persons with Disabilities (BiG-i)
Address: 1-8-1 Chayamadai, Minami-ku, Sakai City, Osaka 590-0115 Japan
Phone: 072-290-0962 Fax: 072-290-0972