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Personal Information Form 2017 Pageant Registration - Personal Information Form Check Applicable Miss Connecticut USA® Pageant Miss Connecticut Teen USA® Pageant Miss Indiana USA® Pageant Miss Indiana Teen USA® Pageant Miss Pennsylvania USA® Pageant Miss Pennsylvania Teen USA® Pageant Miss Vermont USA® Pageant Miss Vermont Teen USA® Pageant Miss West Virginia USA® Pageant Miss West Virginia Teen USA® Pageant These pageants are independently conducted and produced by Sanders & Associates, Inc., under license from The Miss Universe Organization . MISS USA® and MISS TEEN USA® and all variants therefore, and the “Woman with Stars” Logo and the crown designs are all registered trademarks and copyrights of The Miss Universe Organization Name ______________________________________________________________________ Address__________________________________________City________________________State____Zip_________ Date of Birth ______________ Age (as of Pageant weekend) ______ Age (as of 1/1/17) _______ Must be at least 14 but under 27 years of age on this date Height ________ Weight _____ Hair Color ________________________ Eye Color _______________________ Home Phone Number____________________________ Cell Phone Number _________________________________ Parent Name(s) ______________________________________________ Parent Phone Number__________________ Parent Address_____________________________________City______________________State___Zip___________ Father’s Occupation_______________________________ Mother’s Occupation_______________________________ Please list any pageant titles you currently hold _________________________________________________________ _______________________________________________________________________________________________ We require all contestants to provide a valid e-mail address to receive periodic correspondence. Please list the address that you would like to have the information sent to. You may list a parent’s email address if you do not have one of your own. Please print legibly. E-mail Address: _____________________________________________ @ _________________________________ Please list occupation or name of school if student: _____________________________________________________ Please Circle One a) Are you currently and will you continue to be a permanent resident of the state for which you are applying to compete in, for the full 6 month period prior to the state pageant? YES NO b) If no to the above, are you an out-of-state resident who is attending and has completed on full-semester at a college YES NO or university in the state that you are applying to compete in? c) Do you or anyone in your immediate household or family currently work for (paid or volunteer) the state pageant, IMG Universe, LLC YES NO d/b/a The Miss Universe Organization, IMG Worldwide, LLC, Ernst & Young, and their respective parents, subsidiaries, affiliates, and others. Explain:____________________________________________________________________________ d) Have you ever appeared on or applied to any television contest, game show or reality show? YES NO Explain:____________________________________________________________________________ e) Have you ever been charged with the admission of a crime, appeared in public or photographed in a state of full or YES NO partial nudity, or engaged in any illegal activity that might bring disrepute or scandal to yourself? Explain:____________________________________________________________________________ f) Are there any images of you on a public website or forum (such as MySpace, Facebook, Webshots, Modeling/Acting sites, etc…) YES NO Check: Twitter Facebook Instagram Modeling/Acting sites Other:_____________________________ g) Do you have a valid U.S. Passport? (Not required to compete in the state pageant) YES NO *Answers to any of the above questions may not necessarily lead to disqualification; however, it is important that we are made aware so that your eligibility can be determined.* To qualify, you must be (1) a female (2) a citizen of the United States (3) between the ages of 14 and 27 on 1/1/2017 and (4) never have been married, had a marriage annulled, be a parent, have given birth to a child, nor be pregnant. Please read and sign the back of this document APPLICATION & AGREEMENT Where (STATE) appears in this Application & Agreement, it is to be understood as the state and/or state pageant in which you are applying to compete, which is an official preliminary to the 2017 MISS USA® Pageant or the 2017 MISS TEEN USA® Pageant Independently produced by Sanders & Associates, Inc. Please Read Very Carefully! I hereby apply as an entrant in the 2017 MISS (STATE) USA® Pageant or 2017 MISS (STATE) BIOGRAPHY IN CONNECTION WITH MY STATE PAGEANT, INCLUDING USE IN TEEN USA® Pageant (together, the “State Pageants”) and for the opportunity to compete in the PROMOTIONAL AND ADVERTISING MATERIAL. national finals of the MISS USA® Pageant or MISS TEEN USA® Pageant, as the case may be, and I represent to and agree with the State Pageants as follows: 13. I understand and agree that all issues as to my eligibility or that of other contestants shall determined by the State Pageants and The MISS UNIVERSE ORGANIZATION, and I REPRESENTATIONS: agree to abide by that determination both as to myself and other applicants. Any decision to disqualify any contestant or titleholder shall likewise be made by the State Pageants and The 1.MISS: I will be at least eighteen (18) and under twenty-seven (27) years of age on January1, 2017. MISS UNIVERSE ORGANIZATION, and I agree to abide by that determination both as to myself and other applicants. 2.TEEN: I will be at least fourteen (14) and under nineteen (19) years of age on January 1, 2017. 14. I agree to abide by all the rules of the MISS (STATE) TEEN USA® Pageant or the MISS 3. I am not married, have never been married, and have never had a marriage annulled. I have never (STATE) USA® Pageant and the MISS USA® Pageant or MISS TEEN USA® Pageant now in given birth to a child and am not now pregnant nor am I a parent of an adopted child. If any of effect or as announced from time to time hereafter. these conditions change, I will notify the State Director immediately, and I understand that this may affect my eligibility. 15. I understand and agree that my acceptance as a contestant for the title of MISS (STATE) TEEN USA® or MISS (STATE) USA® and my continued consideration for the title of MISS 4. I have never participated in a previous national MISS USA® Pageant (for Miss (STATE) USA (STATE) TEEN USA® or MISS (STATE) USA® is under the sole and complete discretion of contestants) or MISS TEEN USA® Pageant (for Miss (STATE) Teen USA contestants). the State Director of the MISS (STATE) TEEN USA® or MISS (STATE) USA® Pageant. 5. I have not participated and will not participate in any other state’s preliminary pageant (including 16. I agree to permit my photograph, voice recording, and name to be used without charge for any pageant preliminary to another state pageant) to the 2017 MISS USA® Pageant or the 2017 all publicity and commercial purposes and any telecasts of the state and national pageants. MISS TEEN USA® Pageant, including the District of Columbia. 17. I agree that, if I win or succeed to the title of MISS (STATE) TEEN USA® or MISS 6. Prior to the date of this Application and Agreement, I have not been engaged in any activities (STATE) USA®, the terms of this Application and Agreement, including, without limitation, which, if disclosed to the public, would bring or tend to bring myself or the State Pageants into Sections 17 through 22, inclusive, shall continue to be binding upon me, and that any breach disrepute, ridicule, or contempt. I am in good health and of good moral character. thereof shall, in addition to any other right or remedy of the State Pageants (including without limitation my disqualification, loss of title and return of prizes), entitle the State Pageants 7. I am recognized medically and legally as a female in the United States and a citizen of the United to equitable relief and the costs and expenses of obtaining the same, including reasonable States and at least one of the following is true: (a) I now reside and have resided in (STATE) as my attorneys’ fees. permanent and primary residence for a period of at least six (6) months immediately prior to the ® beginning of the 2017 MISS (STATE) TEEN USA® Pageant or the MISS (STATE) USA® Pageant 18. I understand and agree that if I win or succeed to the title of MISS (STATE) TEEN USA ® which I have entered (although I may have attended college or university elsewhere); or or MISS (STATE) USA , as one of my obligations, I will go to and stay in the host city during ® ® (b) I have resided in (STATE) as a full-time student at a college or university for one entire the time required for me to appear in the MISS USA Pageant or MISS TEEN USA Pageant. semester immediately prior to the beginning of the 2017 MISS (STATE) TEEN USA® Pageant or the MISS (STATE) USA® Pageant which I have entered, and I am continuing to reside in 19. I understand and agree that if I win or succeed to the title of MISS (STATE) USA® or (STATE) as a full-time student (although I may have spent or be spending the summer in another MISS (STATE) TEEN USA®, all decisions concerning my preparation for the MISS USA® or state). MISS TEEN USA® Pageant shall be made by my State Director. To this end, and by way of 8. Neither I nor any member of my immediate family or anyone living in my household is currently example and not limitation, I agree (i) to
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