3135-0098 Panelist Profile Form

National Endowment for the Arts

Panelist Profile Form

Panelist Profile Form

Mr. Mrs. Ms. Dr.

Last Name	First Name		Middle
     	     		     
Cell Phone (area code/number)	Home Telephone (area code/number)
     	     
Work Telephone (area code/number)	FAX (area code/number)
     	     
E-Mail Address
     
Title, Role, or Profession
     
Organization (if applicable)
     
     
Mailing Address (home work )
     
     
City		State	Zip Code
     		     	     
Other Address (home work )
     
     
City		State	Zip Code
     		     	     

Are you self-employed/freelance? yes no Do you consider yourself a layperson? yes no

Special Characteristics:
Which of the following describes your ethnicity? Please select only one: Hispanic or Latina/o Not Hispanic or Latina/o Which of the following describes your race? Please select one or more: American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Select one category: Female Male
	Select the appropriate category(ies):
	Visual impairment Hearing impairment Mobility impairment Other impairment Language Skills Please indicate here if you have reading and oral comprehension skills in the following languages Spanish French Other      _________________________________________ Source of Recommendation
	     ____________________________________________________

Arts Expertise    

(See List of Codes on pages 5-10 of the Instructions for appropriate numbers)

Field Role Specialization

Primary Arts Expertise		 	 		 	 	 		 	 	 
Other Arts Expertise		 	 		    	 	 		 	 	 
Other Arts Expertise		 	 		 	 	 		 	 	 
Other Arts Expertise		 	 		 	 	 		 	 	 
Other Arts Expertise		 	 		 	 	 		 	 	 
Other Arts Expertise		 	 		 	 	 		 	 	 

Type of Organization

Select up to five types of organizations with which you have had arts experience:

Arts/Cultural Organizations Funding Organizations

performing arts (dance, folk arts, music, public

opera, musical theater, theater) private

non-performing arts (design, folk arts, corporate

literature, media, museums, visual arts)

arts service organization Media/Journalism

regional arts organization commercial film/radio/television

state arts agency public broadcasting

local arts organization independent production company

artists’ community/live work space newspaper

other trade publication

scholarly journal

Education

(organization, school association) Museums/Galleries/Spaces

pre-kindergarten/early childhood level art

K-12 level natural history/history

college/university level university

professional school

professional association Publishing

other commercial

university

independent press

arts periodical

general periodical

distributor/wholesaler

Additional Information

Add information below which further identifies your expertise (only if not provided on this form or in your resume).

     
     
For Office of Panel Operations Use Only:
Review completed by:      	Date:      	Input completed by:	Date:

OMB No. 3135-0098 Exp. 8/31/2009