Contestant Application Form - The IBM Stage Contest

The I.B.M. Stage Contest Application
The Gold Medal International Award of Excellence

Applicant's Full Name: *

Stage Name (if any):

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: *

Select one: *

Adult (18 and older)

Youth (7 to 17, signature of legal guardian will be required)

Are your dues paid in full through July 2010?: *

Yes

Are there any pyrotechnics (flames or sparks) in your act?: *

Yes

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.

Agreement: *

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.

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