International Magicians Society
International World Headquarters
581 Ellison Ave.
Westbury, NY 11590   USA
516-333-2377       fax: 516-333-6328
info@magicims.com

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Examination for Degree of
DOCTOR OF MAGIC

Cover Sheet

Please Print

                                                                                                                        I.M.S. Membership #_________________

Name__________________________________________________________________________________________
                 First                                               M.I.                                                Last

Address________________________________________________________________________________________

City______________________________________  State_______________  Zip______________________________

Home Phone____________________________________________  Best time(s) to call_________________________
Area Code                                                                                                                     

Business Phone__________________________________________  Best time(s) to call_________________________
Area Code                                                                                                         

E-mail Address___________________________________________________________________________________

Payment of $25.00 Examination Fee is by:

_____ Check             ______Money Order           ________Visa/Mastercard Credit Card

Credit Card Number:_________________-_________________-_________________-_________________

Expiration Date:_________________  Signature:___________________________________________________
month/year                                    card holder's signature ONLY          

CVV Code:____________(the last three numbers on the back of your credit card near your signature)

Billing Address of Credit Card:_____________________________________________________________________

                                                  _____________________________________________________________________

                                                  _____________________________________________________________________

Please Note
The Examination Auditors will not accept or grade your Answer Sheets without this COVER SHEET and/or the $25.00 Examination Fee.