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Birthplace [[blank line]] (Town) (State) Country) Month, and Date of Birth [[blank line]] Education (list of degrees if any and from what institution) [[blank line]] Professional Biography [[blank line]] Enclosed is a check or money order for $15.00. (Check must be sent in with application). Signed: [[blank line]] Recommended by: Edgar Bergen Ben Franklin, Jr. Hal Holbrook Dan T. Moore Drew Pearson Ambassador Enrico Tejera Please mail to INTERNATIONAL PLATFORM ASSOCIATION 2654 Berkshire Road, Cleveland Heights, Ohio 44106