Please Fill in All Information Requested Including Your USFS # and Obtain All Required

Please fill in all information requested including your USFS # and obtain all required signatures. Non-NESC members must get permission to test from their home club. Deadline 14 days prior to test date of: ______

Skater’s Name______USFS #______

Phone______Email______

Address______City______State_____Zip______

Last Test Failed______Date______Last Test Passed______Date______

Parent’s or Adult Skater’s Signature______Partner /USFS#______

Coach’s Signature______USFS#______Email______

Permission to Test: This is to certify that the above-named skater is a member in good standing of

______and has permission to test. Test Chair/Auth Signature______

Check: Solo____ Adult____ Master____

Please circle test(s) you wish to take:

Preliminary: Dutch Waltz / Canasta Tango / Rhythm and Blues

Pre-Bronze: Cha-Cha / Swing Dance / Fiesta Tango

Bronze: Hickory Hoedown / Willow Waltz / Ten-Fox

Pre-Silver: Fourteenstep / Foxtrot / European Waltz

Silver: Silver Tango / American Waltz / Rocker Foxtrot

Pre-Gold: Kilian / Blues / Paso Doble / Starlight Waltz

Gold: Viennese Waltz / Argentine Tango / Quickstep / Westminster Waltz

Free Dance: Juvenile / Novice / Junior / Senior

MEMBER FEES: 1 2 3 4 NON-MEMBER FEE 1 2 3 4

Prelim / Pre-Bronze / $15. / $20. / $25. / Prelim /Pre-Bronze / $20. / $40. / $60.
Bronze / $20. / $25. / $45. / Bronze / $30. / $50. / $70.
Pre-Silver / $25. / $30. / $35. / Pre-Silver / $35. / $55. / $65.
Silver / $30. / $35. / $40. / Silver / $40. / $50. / $60.
Pre-Gold / $30. / $35. / $40. / $45. / Pre-Gold / $45. / $55. / $65. / $75.
Gold / $35. / $40. / $45. / $50. / Gold / $50. / $60. / $70. / $80.
Fr Dance Juv/Nov / $15. / Fr Dance Juv/Nov / $20.
Fr Dance Jr / Sr / $25. / Fr Dance Jr./Sr. / $35.

Total Test Fees: ______

Plus ______(Add Mandatory Hospitality Fee- Member $5.00 / Non-Member $10.00)

= Total Enclosed:______ Please make checks out to “NESC”.