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Circle preferred date
Exam Dates		Location	Application Deadline Postmark
Sat. & Sun. May 14 and 15, 2005		George Mason University, Fairfax, VA	April 16th, 2005
Exam Dates		Location	Application Deadline Postmark

Name of Student_____________________________________ Grade_____ Age ______

Address_______________________________________________________________________

Phone_______________    E-mail __________

Using Accompanist Circle YES or NO

Teacher's Name __________________________ Phone ____________E-mail ________

Address______________________________________________________________

Teachers: Enter preferred dates and time for helping as MONITOR, as needed ________

Teacher membership in ASTA/VA with NSOA is required.

The signature(s) below indicate(s) that I understand the rules governing this event and agree to abide by them.

Teacher's signature: ___________________________________________

Teachers, please duplicate applications as needed. Collect all fees and application forms.

 Make out one check to ASTA/VA with NSOA, and send to:

Lynne Denig, Certificate Program
4900 Bexley Lane, Fairfax, Va. 22032
Tel: (703) 425-1234
email:lynne@asta.net

 Instrument ______________________________________ Level_______

Check box if appropriate: Level B  Comments Only � Honors �

Works to be performed:

1. Title_______________________________ mvt ____ Composer _________________

2. Title_______________________________ mvt ____ Composer _________________

3. Title ______________________________ mvt ____ Composer _________________

4. Etude ______________________________________ Composer _________________

5. Scales and Arpeggios ___________________________________________________