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• This application form is for Visby Residencies in 2011.
• Fields marked * are required.
• Applicants must be South African citizens or permanent residents.
• Rather than complete this online form, the application may be completed on a print-out of a PDF — download the PDF version and fax the completed, signed form to 086-544-4202.
• Visby programme details and conditions.

Name

Title

First Name *

Middle Names

Last Name *

Date Of Birth / Nationality

Date Of Birth *

Nationality
I am a South African citizen or resident *

Contact Details

Phone: Home

Phone: Work

Phone: Mobile

Fax: Home / Work

Email Address *

Web Site / Page

Home Address

Building / No. and Street Name *

Building / No. and Street Name (cont.)

Town / City *

Postal Code

Country *

Work Postal Address

P O Box / Street Address *

Town / City *

Postal Code *

Country *

Short CV

Short CV *

Works And Performances

Five most important works and performances to date *

Motivation

Motivation for requesting a residency at Visby *

Proposal For Visby

Proposal for work you will do at Visby *

Referee Details

Referee 1

Name *

Phone Number / E-mail / Postal Address *

Referee 2

Name *

Phone Number / E-mail / Postal Address *

Comments

Any other comments

Verification

Kindly enter the text you see *

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