NAME: ______________________________________________________________________________________
ADDRESS:  __________________________________________________________________________________
CITY: _______________________________________  STATE: ___________  ZIP CODE:  __________________
PHONE: ________________________________  E-MAIL:  ____________________________________________

GRADE IN SCHOOL: _______________________________ BIRTHDATE: ____/____/______
SCHOOL: ________________________________________________ Instrument/Voice: ____________________
SCHOOL ENSEMBLE for Wind and String Players __________________________________________________
SCHOOL MUSIC TEACHER or PRIVATE TEACHER  ________________________________________________
TEACHER'S signature and phone number ______________________________________   __________________
ACCOMPANIST'S name, signature and phone number _______________________________________________
____________________________________________________________________________________________

Concerto or Solo Work to be Performed

Composer: _______________________________ Title: _______________________________________________
Movement/s:  _________________________________________________________________________________
Performance Time: _______________________


APPLICANT'S signature ________________________________________________________
(This application may be photocopied)

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Submit this Application and $10.00 non-refundable fee (payable to AMICCO) to:
James Stoltie, President, AMICCO Board
6222 Skyward Court
Bradenton, FL 34203

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