Big Brother Canada LONG FORM APPLICATION

CONTACT INFORMATION

First Name______Middle______Last______

Full legal name as it appears on your travel documents is required above

Nickname /Aliases / Maiden Names: ______

Have you ever formally or otherwise changed your name? If so, what other names have you used and why? ______

______

Hair Color:______Eye Color:______

Address: ______Home Phone:______

City: ______Work Phone:______

State ( Province ): ______Mobile: ______

Zip ( Postal Code ):______Fax: ______

Email address: ______Face book / Twitter / Other: ______In what town / city did you grow up? ______What city do you currently reside in? ______Closest Airport: ______Emergency Contact: ______Phone: ______

EMPLOYMENT / EDUCATION

Highest level of education completed: ______What college or University did you attend? ______

Degree(s): ______

Current Occupation: ______How long at current Job? ______

*Current Employer: ______

If you are a student, what is your major / field of study and what year of study are you currently in? ______

PERSONAL

1.What is your marital status? IE: Single, living common-law, married, divorced, separated, widowed, dating. ______

2.Do you have any children? If yes, please list their name(s) and age(s). ______

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3.Which (3) books would you take with you to a deserted island and why? ______

4.Which television programs do you always watch and why? ______

5.Which television programs do you never watch? Why not? ______

6.Do you play a musical instrument? If yes, what instrument do you play? ______

7.Are you active in any of the following: Dancing / singing / acting / playing music in a band or orchestra / writing poetry / inventing things / chess / painting / sculpting ? If yes, please describe any achievements in these fields. ______

8.Do you have any other creative, artistic or intellectual hobbies? If yes, please explain. ______

9.Are you a smoker? If yes, how many cigarettes per day do you smoke? ______

10. Do you drink alcohol? If yes, how often, how much per week? ______

11. What is your favorite alcoholic drink? ______

12. Do you use any drugs? If yes, what and how often? ______

13.Do you consider yourself a good cook? ______

14.What is your favorite meal? ______

15.Are you a vegetarian? ______

16.What is your favorite color?______

17.Are there any foods you do not eat or are not allowed to eat? What and why not? ______

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18.Do you have any pet(s)? If yes, what kind of pet(s) and what are their name(s)? ______

19.What sports do you play? ______

20.What sports do you like to watch? ______

21.Do you think politics are important? Clearly state why or why not. ______

22.If you could become the leader of a political party, which party would that be? Please explain. ______

23.Do you think it’s important for people to be religious? Please explain. ______

24.Are you a member of any organizations or associations? If yes, please explain. ______

25.To which charitable organization(s) should people donate money? Why? ______

26.Besides your work, study or household, are there any other activities you participate in or ways in which you spend your time? Briefly describe what you do? ______

27.Which newspapers and / or magazines do you read? ______

28.List (3) of your favorite movies: ______

29.What type(s) of music do you listen to? ______

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30.Do you believe in astrology? Explain why or why not? ______

31.What achievement in your life are you most proud of? Please explain. ______

32.What does “the best day in your life” look like? ______

33.What motto do you live your life by? ______

34.Do you have a hero or an idol? Who and why? ______

35.PLEASE ANSWER TRUE OR FALSE TO THE FOLLOWING (9) STATEMENTS – PLEASE GIVE EXPLANATIONS TO EACH ANSWER.

A. Women who have children should make their career second to their children B. All doors are open for famous people C. Men who cry look like fools D. People who stick to their principles are not flexible E. People who cannot quit smoking are weak F. If you do not like animals – then you don’t like people G. Religions are old fashioned H. Having an affair is better than getting a divorce I. If you are in a fight it is better to bend than to break

BACKGROUND

36.Have you ever been in trouble with the police? If yes, why and when? Clearly describe what happened. ______

37.Did they conduct a preliminary hearing against you? If yes, why and when? Clearly describe what happened. ______

38.Has criminal action ever been taken against you? If yes, what was the charge and were you acquitted? Clearly describe what happened and why you were acquitted? ______

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39.Have you ever been criminally convicted? If yes, why and when? What sentence did you get? Clearly describe what happened. ______

40.Are there any other facts or events that have drastically changed your life? Large debts or bankruptcy / divorce or break-up / losing family or friends? Please describe below. ______

41.Have you ever applied to, or participated in a TV program? If yes, what program and when? ______

MEDICAL / PSYCHOLOGICAL

42.Have you ever been treated for a serious mental or physical illness? If yes, please describe precisely what the illness was, which treatment you received and when this happened. ______

43.Are you currently receiving treatment for a mental or physical condition? If yes, please explain ______

44.Do you use any prescribed medications? If yes, please list all medications and what you take them for. ______

45.Do you have any allergies? If yes, please list any/all. ______

46.Were you ever or are you currently being treated for any addictions? IE: Gambling, alcoholism, drugs etc. If yes, please describe the type of addition, treatment and for how long have you been seeking treatment. ______

47.What do you expect participating in Big Brother Canada will bring you? ______

SHOW SPECIFIC

48.What character traits of other people annoy you? How do you deal with them? ______

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49.What is the most important aspect of the Big Brother project for you? ______

50.What type of person are you hoping will be joining you in the Big Brother house and why? ______

51.What type of person are you hoping will NOT be joining in the house with you and why? ______

52.What is your biggest fear about possibly moving into the big brother house? ______

53.Please complete the following sentence: I am applying for Big Brother because… ______

54. In 30 words or less, please tell us why we should absolutely choose you to participate in Big Brother Canada? ______

55. Please indicate below any schedule conflicts you may have during the casting process and tentative shoot dates of the show. ( Nov 25 – 30, 2012 & Feb 1 – May 30, 2013 ) Please explain. ______

All information that Applicant provides to Insight-Big Brother Canada Ltd. (“Producer”) in this agreement or otherwise (including as acquired through any background investigations as permitted herein), including but not limited to “personal information” governed by applicable privacy legislation, will be used solely for the purpose of making casting and other similar decisions for the production and public broadcast of Big Brother Canada (the “Program”), any subsequent seasons of the Program, and any ancillary or related productions, including “making-of’ and “behind-the-scenes” productions, and/or for all publicity and promotional purposes related thereto. By signing this agreement, Applicant hereby authorizes Producer and/or its authorized agents to undertake a background investigation of Applicant including, but not limited to, a criminal background check, a previous employment check, a references check, an education verification check and verification of any and all information Applicant has provided, and Applicant authorizes all corporations, companies, educational institutions, persons, law enforcement agencies, criminal, civil and federal courts, and former employers to release information they may have about Applicant to Producer and/or such authorized agents. In the course of these investigations, Producer may be required to disclose to these entities personal information that Applicant has provided to Producer or that Producer has obtained from third parties. In the event that Producer thinks, in its sole discretion, that disclosure to a third party is necessary to carry out any services it requires to produce the Program, Applicant authorizes Producer to disclose Applicant’s personal information to these service providers. By signing this agreement Applicant consents to the collection by Producers, Shaw Media Inc. and it’s respective affiliates, subsidiaries, related companies, advertising and promotional agencies (collectively, “Released Parties”) of Applicant ’s personal information by the Producer for the purposes stated in this paragraph. Producer shall not use this agreement (including any photographs or other personal information) for any purpose not disclosed in this paragraph, the agreement, terms and conditions applicable to the Program, and/or the release forms without contacting Applicant first for permission to do so. Applicant hereby release Released Parties from any and all liability arising out of the collection, use and disclosure of Applicant’s personal information in the ways stated in this agreement and Applicant agrees not to make any claim against Released Parties in respect of such use (including, without limitation, any claim that such use invades any right of privacy and/or publicity and any claims based on defamation or false light).

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CERTIFICATION OF VERACITY

1. I have voluntarily applied to participate in the television program currently entitled “Big Brother Canada” (the “Program”) being produced by Insight-Big Brother Canada Ltd. (“Producer”) for intended exhibition by Shaw Media Inc., and/or Slice Network Canada (collectively, the “Network”). In order to be considered as a participant in the Program, I have made and will make statements and representations to Producer and to the Network regarding myself and my background. I understand that this information is being relied upon by Producer and by the Network in considering me for selection as a participant in the Program.

2. I hereby certify, represent and warrant that all statements, disclosures and representations made by me in my application to participate in the Program, in any other document or agreement that I have signed or will sign in connection with the Program or my participation in the Program, and that I otherwise provide to Producer, to the Network, or to anyone acting on their behalf, are true, accurate and complete. Without in any way limiting the foregoing, I certify that I have not withheld or mischaracterized any information regarding myself or my background.

3. If any statement, disclosure or representation is false, misleading or incomplete, Producer and/or the Network may remove me from consideration as a participant in the Program, may remove me from the Program, and/or may withhold from me or cause me to return any prizes, monies (including any compensation), or other items that I have won or received, including, without limitation, any prizes, monies, or other items already delivered to me.

4. I also recognize that proof of damages suffered by Producer and the Network in the event that I breach any provision of this certification will be costly, difficult and/or inconvenient. Accordingly, I agree to pay Producer and the Network the sum of One Million Canadian Dollars (CDN$1,000,000) per breach plus disgorgement of any money or the value of anything that I may receive in connection with my breach as liquidated damages in the event I breach any provision of this certification. Furthermore, I will indemnify and hold harmless Producer, Shaw Media Inc., the Network, and their respective parent, subsidiary and affiliated companies, and each of their respective officers, directors, agents, representative and employees, from and against any and all claims, actions, damages, liabilities, losses, costs and expenses (including, without limitation, attorney’s fees) that in any way arise out of or result from my breach of any provision of this certification.

ACCEPTED AND AGREED:

Applicant Signature: Date:

Print Name:

Witness Signature: Date:

Print Name:

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