1. Name: __________________________________________________________________________

2. Birth Date: (month)_____ /(day)_____ / (year)______ 3. Age as of November 18, 2011: _________

4. Form of I.D. you are enclosing (copy of): Birth Certificate____ Passport____ Driver's License____

5. Current Address: ___________________________________________________________________

6. Current Email Address: ______________________________________________________________

7. Current Phone #: ___________________________ 8. Home Phone #: _________________________

9. Permanent Address: _______________________________________________________________

10. Will you need local accommodations?(only for those who are eligible) Yes____ No____

11. Will you need an accompanist? Yes____ No____

12. How did you hear about The 2011 Heida Hermanns International Piano Competition?
(please select all that apply)

Posting at school____ Internet____ My music teacher____

Other (please explain) __________________________________________________________________

_

PLEASE LIST YOUR COMPETITION REPERTOIRE

1. For Your Three Audition Recordings - Refer to instructions regarding providing and labeling
tapes or CDs.

For the Semi-Finals
A TYPED LIST IS REQUIRED - Use separate sheet if you need more space. THANKS.

Composer-------------------Full Title--------------------------------Movements------------------------Timing
_______________________________________________________________________________________

For the Finals PLEASE BE PREPARED TO SUBMIT YOUR PROPOSED FINALS REPERTOIRE AT COMPETITION REGISTRATION DESK. Same format as above. Limited to approx 20 minutes (It will be discussed with the Artistic Director if you proceed to the Finals.)

I certify that all information given above is correct to the best of my knowledge. I agree that the
decisions of the judges shall be final, that I will make no claims of any kind against the Competition
or Connecticut Alliance for Music, Inc., and that I shall assent to and comply with all rules and
regulations of the Competition. I also understand that the Semi-Finals Auditions and the Finals
Concert might be recorded and the recordings used by Connecticut Alliance for Music, Inc., for
promotional purposes. I give permission for my performance(s) during the Competition to be
recorded for this use.


Signature: ____________________________________________ Date: ____________________