Documente Academic
Documente Profesional
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CONTACT INFORMATION
Your Full Name (Including Maiden and aliases)
Mobile:
Work:
E-mail:
Address:
Gender: M F
Spouse’s Name:
Occupation:
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SEARCH INFORMATION
(If you were not adopted, what were the circumstances of your separation?)
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NAME(S):
AGE(S):
DATE OF BIRTH:
OCCUPATION(S):
MEMBERSHIP IN CLUBS:
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FORMER SCHOOLS:
________________________________________________________________
________________________________________________________________
CRIMINAL RECORD:
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
1. Name:
Contact information:
Relation to Person you are seeking:
2. Name:
Contact information:
Relation to Person you are seeking:
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ABOUT YOU
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ENTERTAINMENT EXPERIENCE
1.Show Title:
Show Contact information:
2.Show Title:
Show Contact information:
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MEDICAL INFORMATION
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ADDITIONAL INFORMATION
HAVE YOU EVER BEEN ARRESTED OR HAD A RESTRAINING ORDER
PLACED AGAINST YOU?
YES NO (CIRCLE ONE AND IF SO, PROVID ECHARGE AND WERE YOU
CONVICTED?)
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1. Name:
Contact information:
Relation to Person you are nominating:
2. Name:
Contact information:
Relation to Person you are nominating:
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I acknowledge that all of the information provided on this application is true and
accurate, and any false or misleading information submitted herein is grounds for my
immediate elimination from consideration. I agree that Clock Tower Productions, Inc.
and Straight Wharf Productions, LLC (collectively, “Producer “) have the right to
interview me in connection with my application to participate in the Series and that any
such interview may be filmed or taped. The information contained on this application,
any filmed or taped interview material and any other material submitted by me including,
but not limited to, pictures, film and videotapes (the “Material”), becomes the property of
Producer and shall not be returned, and may be used in any manner in all media,
throughout the universe, in perpetuity. I acknowledge that Producer may determine in its
absolute discretion whether or not to select me to participate in the Series and that
Producer has the right to end the audition process, or to eliminate me from further
consideration as a participant or potential participant at any time for any reason. In
connection with this application, I agree to sign such other releases, consents,
authorizations and other documents as Producer may require.
I and the other Releasing Parties acknowledge that there is a possibility that
subsequent to the execution of this release, I or they will discover facts or incur or suffer
claims that were unknown or unsuspected at the time this release was executed, and
which if known by me at that time may have materially affected my decision to execute
this release. I and the other Releasing Parties acknowledge and agree that by reason of
this release I and the other Releasing Parties are assuming any risk of the existence of
such unknown facts and such unknown and unsuspected claims. I and the other
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Releasing Parties have been advised of the existence of Section 1542 of the California
Civil Code, which provides:
I authorize Producer to conduct drug testing, medical testing, psychological and physical
examinations of me in order to determine my fitness to participate in the Series. I further
authorize the individuals conducting such examinations of me to disclose to Producer and its
representatives all information about me obtained in connection with such examinations. I
authorize Producer to investigate, access and collect information about me and my
background, including without limitation: to secure information about my experiences from
my current and former employers, associates, friends, co-workers, family members,
educational institutions, government agencies, credit reporting agencies, and any references I
have provided; and to investigate my employment record, educational records, medical
records, government records (e.g., motor vehicle record, criminal record, civil litigation
record), employment eligibility and credit reports.
In connection with my application to audition for the Series, Producer may reveal to me or I
may otherwise obtain confidential or proprietary information regarding Producer or the
Series (“Confidential Information”). This Confidential Information may include, among
other things, information regarding the identity of other applicants and the Series format or
sponsors, or the nature or results of any Series challenge or competition. I agree that I will
not directly or indirectly at any time publish, reveal, disseminate or otherwise disclose, or
cause to be published, revealed, disseminated or otherwise disclosed any Confidential
Information to any third person, including family members and news media. I acknowledge
that if I disclose any Confidential Information, Producer and Network will suffer serious and
irreparable harm, which will entitle Producer and Network, among other remedies, to seek
injunctive relief and to recover liquidated damages in the amount of $1,000,000.
This agreement shall be governed by the laws of the state of California. By signing this
Participant Application and Release, I represent and warrant that all of the
information in this application is true and accurate and that I assent to all of the
terms and conditions set forth above.
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