Printable Application Form

      International Academy of Music
                  Application Form
             Saint Petersburg, Russia

Name_______________________________________________

Male (__) Female (__)

Address_____________________________________________

City_______________ State_______ Zip Code______________

Country____________________________ Age______________

Telephone (___)____________Fax (___)___________________

E-mail address_________________________________________

Instrument or Voice Type__________________ Years Studied____

Accomplishments_______________________________________

____________________________________________________

Teacher’s name _______________________________________

School______________________________________________

Signature of student (If student is 18 or over)

____________________________________Date____________

Signature of parent or guardian (If student is under 18)

_____________________________________Date___________

Please mail this completed form with:

1. A deposit of US $700.00 and
2. An application fee of US $80   before March 1, 2008
                                   (US $100 after    March 1, 2008)
                                   payable to:

DOBBS FERRY PIANO STUDIO (I.A.M.)
547 Saw Mill River Road, Suite 1G
Ardsley, NY 10502
USA