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FISA.

DE INSCRIEREI APPLICATION FORM


Concursul International de pian "Tudor Dumitresce,"
"Tudor Dumitrescu" International Piano Comoetluo;
Editia a X-a
Bucuresti, June 10th - 11th 2017

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NUMEI SURNAME ?Ellli PRENUME/FIRST NAME AL..~J:t ~
DATAl LOCUL NA~TERIII DATEI PLACE OF BlRTHl1:- r. oh ~.O'1:-:- .
TARA/COUNTRY RP~.~N\~ .
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PROFESORI TEATCHERI NUMEI SURNAME ~ ~ .. o.e~~ G.+.~ & .


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CATEGORIAICATEGORY A X.. B........... C........... D............ E .

CONTESTANT'S REPERTOIRE
(Compozitor, Titlu ~iTimpl Composers, Titles and Time)

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Anexez I fEnclose:
a)C.V.
b) certificat de nastere/ Birth certificate
c) chitanta de achitare a taxeil copy of the receipt of the Application fee
LEI (la cursul de schimb al zilei): IBAN: R076BTRLRONCRTOV00042201
EURO: IBAN: R061BTRLCRTEUROV0004220J
BANCA TRANSIL VANIA - Bucuresti, Romania
Asociatia culturala "HARISME", C.I.F. 18494829

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Data Q~J.$)q,emnAturaiSigna~ %'~tura parintilor/ Parentssignaturforminor.,.(:J--

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