The I.B.M. Stage Contest Application
The Gold Medal International Award of Excellence
Applicant's Stage Name (if any): __________________________________________________
Applicant's Full Name: _________________________________________________________
Street Address: ______________________________________________________________
City: _____________________________________
State: ___________________________
Postal Code: ___________________________
Country: _____________________________
Telephone Number: _______________________
Email address: ______________________
IBM Membership Number: ____________________________________________________
City/IBM Ring(s) to which you belong: ____________________________________________
Date of Birth: ____________________________
CHECK ONE:
__ Adult (age 18 & older) __ Youth (7 to 17, signature of legal guardian required)
Are your dues paid in full through July 2010 _____
Are there any pyrotechnics (flames or sparks) in your act? _____
If yes, what type? ___________________
(If yes, please complete the Pyrotechnic Effects sheet.)
How long (in minutes) will it take for you to set your act?: ____________
Please complete the Contest Technical Sheet and bring it with you to the Preliminary Contest meeting.
I certify that the foregoing information is true and correct, that I have read and agree to abide by the Contest Rules and Procedures, and that no knowingly unauthorized use of intellectual property will be included in my contest performances. I agree to indemnify and hold the International Brotherhood of Magicians harmless for any damages, expenses or losses it may incur by reason of claims made against me as a result of my participation in this contest, regardless of the merit of any such claims. I agree to be bound by all decisions of the Contest Judges. I agree that any untrue statements made by me or a breach by me of any covenants contained herein shall be grounds for disqualification.
Signature Date
______________________________________________ _______________________
Signature of legal guardian (if the applicant is under age 18) Date
______________________________________________ _______________________
Mail to:
Don E. Greenberg, I.B.M. Contest Chairman
4450 Peace Valley Road • New Waterford, OH 44445 USA
(330) 457-2345 • Email: d.greenberg@att.net
