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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