Applicant Information: Please attach proof of residency.

Last Name

First

M.I.

Date

Street Address

Apartment/Unit #

City

State

ZIP

Phone

E-mail Address

Talent Description:

Social Security No.

Drivers License No.

Have you competed in a pageant before:

Where:

Are you a citizen of the United States?

YES

NO

Current Age:

Will you submit to a background check?

YES

NO

Possible Platform Topic:

Have you ever been convicted of a felony?

YES

NO

Can you travel?

I am aware that each contestant is responsible to find their own

sponsor: (a sponsor is someone who pays the Registration fee).

(circle one) YES NO Initial Please: _____________

Registration is $100.00.

Do you currently have a sponsor for the pageant: (enter name here) __________________

I am aware that each contestant is responsible

for selling (20) event tickets: YES NO Initial Please: ___________

I agree to find my own sponsor: (signature please) _________________________________

I agree to sell or buy my event tickets: (signature please) ___________________________

Tickets are distributed at orientation. Initial Please: _____________

All ticket monies are due & payable in cash on or before 5/1/2012 Initial Please: ________

Education: Please attach last report card.

High School

Address

From

To

Did you graduate?

YES

NO

Degree

College

Address

From

To

Did you graduate?

YES

NO

Degree

Other

Address

From

To

Did you graduate?

YES

NO

Degree

References

Please list three references.

Full Name

Relationship

Company

Phone

()

Address

Full Name

Relationship

Company

Phone

()

Address

Full Name

Relationship

Company

Phone

()

Address