Personal Information Form

Home , Miss Connecticut, Miss Connecticut USA, Miss Indiana, Miss Indiana USA, Miss Pennsylvania, Miss Pennsylvania USA

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 utilize exclusively the services of the staff of the employed by or has been employed within the last two (2) years by, or is a close acquaintance of MISS anyone employed within the last two (2) years by any State Director in the MISS USA® and/or (STATE) USA® Pageant or MISS (STATE) TEEN USA® Pageant, and each pageant sponsor MISS TEEN USA® pageant system or any company or enterprise that the State Director may own in connection with my preparation for the MISS USA® or MISS TEEN USA® Pageant; (ii) to or control, IMG Universe, LLC d/b/a The Miss Universe Organization (“Miss Universe”), IMG wear, during the evening gown competition of the MISS USA® Pageant or MISS TEEN USA® Worldwide, LLC, and their respective parents, subsidiaries, affiliates, and others (collectively, “the Pageant, a gown provided by the pageant sponsor; (iii) not to engage or continue the services Parties”), or Ernst & Young. . (IF YOU OR ANY MEMBER OF YOUR IMMEDIATE FAMILY IS of or otherwise consult with (for monetary consideration or otherwise) any person, firm or EMPLOYED BY ANY OF THE FOREGOING OR ANY FIRM OR CORPORATION CONTROLLED other entity providing services in competition with a pageant sponsor; or (iv) not to engage or OR AFFILIATED WITH ANY OF THEM, THEN YOU MUST NOTIFY YOUR STATE DIRECTOR continue to use or consult with any interview, stage presentation, or other pageant coaches. I IMMEDIATELY IN WRITING, SO THAT YOUR ELIGIBILITY MAY BE DETERMINED.) understand and agree that any waiver of the provisions hereof shall require, in each instance, the prior written consent of my State Director. Any consent given shall be for the specific AGREEMENTS APPLICABLE TO ALL CONTESTANTS: instance requested and shall not be deemed consent to any other request or instance.

® 20. I represent and agree that, between the date of this Application and Agreement and the 9. I agree that if I win or succeed to the title of MISS (STATE) USA or the MISS (STATE) ® ® ® ® ® MISS (STATE) TEEN USA Pageant or MISS (STATE) USA Pageant, I have not and will TEEN USA , I will participate in the MISS USA Pageant or MISS TEEN USA Pageant, as the not engage in any activities which, if disclosed to the public, would bring or tend to bring, case may be, and abide by all the rules and regulations governing that pageant. If I win the MISS myself or the State Pageants into disrepute, ridicule or contempt. USA® Pageant, then I agree to participate in the MISS UNIVERSE® Pageant and abide by the rules and regulations governing that pageant. 21. I understand and agree that if I win or succeed to the title of MISS (STATE) TEEN USA® or MISS (STATE) USA®, my failure to comply with any of the terms, provisions, restrictions 10. I understand that the sponsorship requirement is due in full prior to the commencement or obligations hereof shall, at the option of the State Director of the MISS (STATE) USA® of the state pageant and agree that I am free to withdraw from the State Pageants at any time prior Pageant or MISS (STATE) TEEN USA® Pageant, result in all or any of my disqualification, to my being crowned as MISS (STATE) USA® or MISS (STATE) TEEN USA®, but under no circumstances will I be entitled to a refund or to transfer to another contestant any fee or loss of title, and my obligation to return immediately any and all prizes awarded.

sponsorship money, either in full or in part, that I or my sponsors have paid. Likewise, if for any ® reason I shall be disqualified from the State Pageants competition, under no circumstances will I be 22. I understand and agree that if I win or succeed to the title of MISS (STATE) USA or entitled to a refund or to transfer to another contestant any fee or sponsorship money, either in full MISS (STATE) TEEN USA®, I will not permit the use of my name, photograph, image, or title or in part, that I or my sponsors have paid. as MISS (STATE) USA® or MISS (STATE) TEEN USA® by anyone without the prior written consent of my State Director. 11. I agree that if I win or succeed to the title of MISS (STATE) USA® or MISS (STATE) RELIANCE BY PAGEANT; EFFECT OF SIGNATURE TEEN USA®, MISS USA® or MISS TEEN USA®, I will not participate in any pageants during the time that I hold either of those titles unless authorized in writing by the State Pageants and MISS UNIVERSE L.P., LLLP. 23. I understand and agree that the State Pageants are relying upon my representations and agreements set forth in this Application and Agreement as a material inducement to accepting ® 12. I HEREBY RELEASE, UNCONDITIONALLY AND FOREVER, ANY CLAIM my Application, and allowing me to compete for the title of MISS (STATE) USA or MISS (STATE) TEEN USA®. Any representations which are untrue or false in any respect, both AGAINST THE STATE PAGEANTS, SANDERS & ASSOCIATES, INC., THE MISS ® UNIVERSE ORGANIZATION, AND THEIR RESPECTIVE PARENTS AND AFFILIATED OR when made and as of the date of the MISS (STATE) USA Pageant or MISS (STATE) TEEN USA® Pageant, or failure to comply with any agreement hereunder or any rule or regulation RELATED COMPANIES AND OTHER RESPECTIVE OFFICERS, DIRECTOR, PARTNERS, ® ® EMPLOYEES, AGENTS AND ASSIGNS, WHICH I MAY HAVE BY VIRTUE OF MY of the MISS (STATE) USA Pageant or MISS (STATE) TEEN USA Pageant of which I have had notice, may result in my disqualification from the MISS (STATE) USA® Pageant or MISS PARTICIPATION IN MY STATE PAGEANT OR BY ANY USE OF MY NAME, LIKENESS, ® VOICE, AND/OR (STATE) TEEN USA Pageant. By my signature below, I, and, with respect to any contestant who is a minor, my parent or guardian, hereby acknowledge that: (i) all information on this application is true and accurate; (ii) I have read and agree to be bound by the eligibility requirements; (iii) even if I meet the eligibility requirements, the State Pageant has no obligation to select me as a contestant; (iv) all decisions by the State Pageant concerning selection of the contestants is final and not subject to challenge or appeal. I understand and agree that my continued participation is contingent upon my meeting the eligibility requirements above as well as those eligibility requirements set forth in any other documents required by the State Pageant. If selected, I agree to execute any waivers, release agreements and/or entry forms required by the State Pageant. Signature of Applicant: ______Date: ______Print Applicant Name: ______Signature of Parent/Guardian: ______Date: ______(Parent /Guardian signature is REQUIRED if applicant is under 18 years of age. Please include your deposit when submitting this form.