Name_____________________________________________

Male (__)             Female  (__)

Address___________________________________________

City_______________ State_______  Zip Code____________

Country____________________________ Age____________

Telephone (___)____________Fax  (___)_________________

E-mail address_______________________________________

Instrument _____________________ Years Studied__________

Accomplishments_____________________________________

__________________________________________________

__________________________________________________

Teacher’s name _____________________________________

Requested teacher ___________________________________

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 15, 2008
                                   (US $100 after    March 15, 2008)
                                  payable to:

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