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Please indicate your fees and method of payment. Note: PO and credit card payments will be adjusted to reflect correct fees as needed unless we are instructed NOT to do so below. If adjustments are NOT authorized, processing will be delayed until complete payment is received.

Studentmembers________at$22.00each = $________ Please list students beginning on next page and complete the last page of this form.

Optionalrushservicefee($45.00additional) = $ NOTE: Box above MUST be checked

Total amount enclosed = $

Studentcertificatesneededby* *This is NOT a guaranteed delivery date.

Checkormoneyorderenclosed(pleasesubmitonlyonecheckormoneyorderperschool)

Schoolpurchaseorderdocumentenclosed.(P.O.numberandadministrator’ssignaturerequired.) initial

DonOtadjustP.O.amount. Chargemy: Visa MasterCard DinersClub AmericanExpress

FeesareineffectAugust1,2010-July31,2011.Feesarenon-refundable.MembershipissubjecttotheEdtAcodeofregulationsandpolicies.Please send ALL materials under same cover to: The International Thespian Society P.O. Box 632347 Cincinnati, OH 45263-2347 Phone: 513-421-3900 Fax: 513-421-7055 www.schooltheatre.org

Accountnumber ExpirationDate

Type or print legibly in black ink only.

troupenumber

troupedirector:Prefix First MiddleI. Last Suffix

Schoolname

PreferredSchoolAddress

City St./Prov Ziporpostalcode

Country

SchoolPhone Ext. SchoolFax

OtherPhone

Check here for RUSH SERVICE $45 additional charge – include payment below

FAXEDforms(PO/creditcard),5-business-daydelivery.MAILED-Informs(all),10-business-daydelivery.nOtE:Errorsonformwillcausedelays.

2010-2011 High School Thespian Induction Roster

Office use only

RosterCompleted_______________

_____Cert.Sent_______________

_____Processed_______________

Preferredtroupee-mail(monitoredregularlybytroupedirector)**usedfore-mailbulletins,processingquestions,orderconfirmations,etc.

PLEASE dO NOT CONFIRm FAx ORdERS By mAIL.

Troupe director: Please make a copy of this report for your records prior to mailing.

initial DonOtadjustcreditcardamount.

CID/Cardcode(required):Amex=4-digit#aboveaccount#onfrontofcard,allothers=last3digitsinsignaturefieldonbackofcreditcard:

Creditcardbillingaddress

Signature

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1.name:First MiddleI. Last Suffix

Male Female Homeaddress

City St./Pr. Zipcodeorpostalcode

E-mail Idonotwishtoreceivescholarship,college,orotherinformationbymail.

Grade: 9 10 11 12 Graduationyear Officeuseonly

2.name:First MiddleI. Last Suffix

Male Female Homeaddress

City St./Pr. Zipcodeorpostalcode

E-mail Idonotwishtoreceivescholarship,college,orotherinformationbymail.

Grade: 9 10 11 12 Graduationyear Officeuseonly

3.name:First MiddleI. Last Suffix

Male Female Homeaddress

City St./Pr. Zipcodeorpostalcode

E-mail Idonotwishtoreceivescholarship,college,orotherinformationbymail.

Grade: 9 10 11 12 Graduationyear Officeuseonly

4.name:First MiddleI. Last Suffix

Male Female Homeaddress

City St./Pr. Zipcodeorpostalcode

E-mail Idonotwishtoreceivescholarship,college,orotherinformationbymail.

Grade: 9 10 11 12 Graduationyear Officeuseonly

Pleaseobtaincurrentaddressinformationfromeachstudent.Donotcopyfromschoolrecords.MAILPOLICY:EdtA/ItSmaysharethespianmailinginformationwithcolleges,universities,orotherorganizationsthatmightbeofinteresttomembers.tooptoutofreceivingmail,checktheappropriateboxforeachthespian.E-MAILPOLICY:Providinge-mailaddressesisoptionalandauthorizesEdtA/ItStosende-mailcorrespondencetomembers.EdtA/ItSdoesnotreleasethespiane-mailaddressestothird-partyvendorsbutmaydelivercarefullyscreenedoffersandinformationonbehalfofselectedschoolsandorganizations.Membersmayoptoutofe-mailcorrespondenceatanytime.

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5.name:First MiddleI. Last Suffix

Male Female Homeaddress

City St./Pr. Zipcodeorpostalcode

E-mail Idonotwishtoreceivescholarship,college,orotherinformationbymail.

Grade: 9 10 11 12 Graduationyear Officeuseonly

6.name:First MiddleI. Last Suffix

Male Female Homeaddress

City St./Pr. Zipcodeorpostalcode

E-mail Idonotwishtoreceivescholarship,college,orotherinformationbymail.

Grade: 9 10 11 12 Graduationyear Officeuseonly

7.name:First MiddleI. Last Suffix

Male Female Homeaddress

City St./Pr. Zipcodeorpostalcode

E-mail Idonotwishtoreceivescholarship,college,orotherinformationbymail.

Grade: 9 10 11 12 Graduationyear Officeuseonly

8.name:First MiddleI. Last Suffix

Male Female Homeaddress

City St./Pr. Zipcodeorpostalcode

E-mail Idonotwishtoreceivescholarship,college,orotherinformationbymail.

Grade: 9 10 11 12 Graduationyear Officeuseonly

9.name:First MiddleI. Last Suffix

Male Female Homeaddress

City St./Pr. Zipcodeorpostalcode

E-mail Idonotwishtoreceivescholarship,college,orotherinformationbymail.

Grade: 9 10 11 12 Graduationyear Officeuseonly

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Pleaseallow3weeksfromthedateofreceiptforustoprocessyournon-rushinductionrosterform.

Certificatesandmembershipcardsforallnewmemberslistedwillbemailedtothetroupedirectoroncethisformandallmembershipfeesarere-ceivedatthehomeoffice.Dramaticssubscriptionswillbegin6-8weeksafterprocessingforstudentsinductedAugust–March.StudentsinductedApril–JulywillreceivetheirfirstissuesinSeptember.

I hereby certify that the students named above have fulfilled all requirements and are worthy of membership in the Interna-tional Thespian Society. I have informed these students that $13.51 of each basic membership fee is payment for a one-year subscription to Dramatics magazine.

Signatureoftroupedirector Date

Student membership Benefits •One-yearsubscriptiontoDramatics (9issues), renewableatadiscountedrate •Membershipcard •Membershipcertificate •Eligibilityforthespianscholarshipprogramsandotherbenefitsthroughouthighschool;namepermanentlykeptonmembershiprollsatthehomeoffice. •Aportionofeachstudent'sfeehelpsfundthespianscholarshipprograms.

10.name:First MiddleI. Last Suffix

Male Female Homeaddress

City St./Pr. Zipcodeorpostalcode

E-mail Idonotwishtoreceivescholarship,college,orotherinformationbymail.

Grade: 9 10 11 12 Graduationyear Officeuseonly

11.name:First MiddleI. Last Suffix

Male Female Homeaddress

City St./Pr. Zipcodeorpostalcode

E-mail Idonotwishtoreceivescholarship,college,orotherinformationbymail.

Grade: 9 10 11 12 Graduationyear Officeuseonly

12.name:First MiddleI. Last Suffix

Male Female Homeaddress

City St./Pr. Zipcodeorpostalcode

E-mail Idonotwishtoreceivescholarship,college,orotherinformationbymail.

Grade: 9 10 11 12 Graduationyear Officeuseonly

Find all the forms and information you need at our website, www.schooltheatre.org