Seventeenth Annual International Chopin Piano Competition

Presented by Fryderyk Chopin Society of Texas, Inc.

Name:

Date of Birth:

Address:

Telephone (including country code):

REPERTOIRE TO BE PERFORMED (in order of performance):

1____________________________________________________

2____________________________________________________

3____________________________________________________

4____________________________________________________

5____________________________________________________

6____________________________________________________

Please check the statements appropriate to your application:

_____ I have enclosed the required documents and the videocassette or DVD. (Non-USA resident send the audio cassette)

_____ I have enclosed $100.00 for my application fee.

_____ I wish to be housed in private accommodations provided by the Chopin Society.

_____ I will take care of accommodations on my own.

_____ I wish to attend the luncheon and winners’ recital on January 17, 2009 and am enclosing $40.00 for the cost of the luncheon.

_____ Please reserve _______ additional places at the luncheon for members of my family or friends. I have included an additional $40.00 per person.

Total amount remitted to the Fryderyk Chopin Society of Texas, Inc.: $_______________________

I understand and agree that the Fryderyk Chopin Society of Texas, Inc. is not responsible for any accidents or injuries incurred as a result of travel to and/or from this/these competition(s).

(Signature of the Applicant, or if minor, parent or guardian)