Houston, TX

Friday, July 8

2:00 PM – 8:00 PM

Northwest Mall

9800 Hempstead Rd.

Houston, TX 77092

AMERICA’S NEXT TOP MODEL

CYCLE 18

PARTICIPANT APPLICATION

Please read the preceding Eligibility Requirements before completing this application. The

Eligibility Requirements contain important instructions regarding the videotape, photographs and other

items, which must accompany any submitted participant application, as well as submission guidelines for

your application package. And remember, above all else, you must BE HONEST! Any answer may be

verified for accuracy. Don’t answer a question hoping to give us the answer we “want” to hear.

Section I: The Basics

1.) First Name ________________Middle Name_____________Last Name__________________

2.) Have you ever formally or otherwise changed your name or used an alias or another name? If so,

what other names and/or aliases have you used?

3.) AGE ______________ DATE OF BIRTH _______/______/_______

PLEASE NOTE: Applicants must be between the ages of 18 and 27 at the time of this

application

4.) Height ______________& Weight ______________LBS

(PLEASE NOTE: You must be AT OR ABOVE five feet and seven inches [5’7”] in height to be

eligible, although Producers reserve the right to make case-by-case exceptions. However, the

Producers are looking for a variety of models, including plus size models.)

5.) Social Security # ______-_____-______ Driver’s License # _________________

6.) Are you a United States citizen? Yes/No

Do you have a current United States passport? (PLEASE NOTE: Participants on the show may

be required to travel internationally) Yes/No If yes, expiration date: _____________

7.) Home Street Address __________________________________________________

City _____________________ State ________ Zip code ____________

Permanent Address ____________________________________________________

City ______________________ State ________ Zip code ____________

8.) Phone (Daytime) __________________ Phone (Evening) ___________________

Cellular (If any) __________________ Pager (If any) ______________________

9.) E-mail Address (If you don’t have one, tell us why you don’t.)

10.) Name, Phone Number, and Address of Closest Friend

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11.) Name, Phone Number, and Address of Nearest Relative

12.) Name and Phone Number of an Emergency Contact and relationship to you

13.) Do you have a homepage on the Internet? If so, what is the address?

14.) Marital Status (Circle one of (a) through (g) and answer each of the accompanying questions as

applicable)

(a) SINGLE

(b) BOYRIEND/GIRLFRIEND

How long? _____________

(c) MARRIED

How long? ____________ How many times? _________

(d) NOT MARRIED, BUT LIVE W/SIGNIFICANT OTHER

How long? _____________

(e) SEPARATED

How long? _____________

(f) DIVORCED

How long? _____________ How many times? _______ _

(g) WIDOWED

How long? _____________

14a.) If you are married or in a relationship, how would you rate your relationship on a scale of 1-10?

Please explain.

14b.) If you are married or in a relationship, how will your partner feel about the potential two-month

separation?

15.) What is the highest level of education you’ve completed? (Circle one)

(a) NO SCHOOLING

(b) HIGH SCHOOL

(c) ASSOCIATE COLLEGE DEGREE

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(d) BACHELOR’S COLLEGE DEGREE

(e) MASTER’S COLLEGE DEGREE

(f) PROFESSIONAL OR DOCTORAL DEGREE

16.) What school(s) did you attend? (Include the city and state)

17a.) Are you a professional performer within the entertainment industry? If so, what do you do?

17b.) Do you have any acting, singing or performing aspirations? If so, tell us your wishes and goals.

17c.) Have you ever appeared on television? If so, in what capacity did you appear and when? Did

you appear on national television?

17d.) Have you ever appeared in any magazines? If so, which magazine and in which issue?

17e.) Do you have any experience as a model OF ANY KIND? If so, please explain, including when

and for what. PLEASE NOTE: You may not be eligible if you have modeled in a national

campaign within the last five (5) years.

17f.) Have you ever had a modeling contract? If so, please list the name and address of the entity with

which you had such modeling contract.

17g.) Do you currently have a modeling contract? If so, please list the name and address of the entity

with which you currently have such modeling contract.

17h.) Have you ever been represented by a manager or agent? If so, please specify what the

representation covered (e.g., modeling or acting).

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17i.) Are you currently represented by an agent or manager? If so, please specify what the

representation covers (e.g., modeling or acting). PLEASE NOTE: If you are currently

represented by an agent or manager and are selected to be interviewed, you must furnish

sufficient evidence to the Producers that you are able to terminate such representation in the event

that you are selected to participate in the show. If selected to participate in the show, you must

terminate, prior to your participation, any representation which conflicts with the terms of your

participation.

18.) Have you ever been arrested? If so, tell us about it (include dates, city & state).

19.) Have you ever been charged with a crime? If so, tell us about it (include dates, city & state).

20.) Have you ever been convicted of a crime? If so, tell us about it (include dates, city & state).

21.) Have you ever had a restraining order issued against you? If so, tell us about it (include dates,

city & state).

21a.) Have you ever had a restraining order issued against someone else? If so, tell us about it (include

dates, city & state).

22.) Are you involved in any pending litigation? If so, tell us about it (include dates).

Section II: Family & Lifestyle

23.) Do you have any children? If so, please list their name(s) and age(s).

24.) Regardless of your marital status, describe your ideal romantic partner.

25.) Describe your relationship with your mother.

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26.) Describe your relationship with your father.

27.) What is your current occupation?

28.) Are you a student? If so, tell us about your major or course of study.

29.) What is your favorite food?

30.) Do you smoke? If so, what do you smoke and how often?

31.) Do you drink alcohol? If so, how often do you drink and how much?

31a.) How often do you get drunk? How do you act when you get drunk?

32.) What are your thoughts on religion?

33.) Are politics important to you? How often do you vote?

34.) Have you had any particularly interesting occupations in your past?

35.) Do you have any pets? If so, please list their name(s) and type(s).

36.) Are you a vegetarian? Do you have any food limitations (e.g. allergies, religious, etc.)?

37.) Have you ever lived with roommates?

38.) What’s your favorite TV show?

39.) What’s your favorite movie?

40.) What kind of music do you like best?

41.) What magazines do you read?

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42.) Do you belong to any affiliations or organizations?

43.) Do you have any body art (piercings, tattoos, etc.)? If so, please describe them.

44.) What’s your favorite sport to play? …to watch?

Section III: Medical & Psychological

45.) Have you been treated for any serious physical or mental illnesses within the last five (5) years?

(Circle one)

(a) YES

(b) NO

46.) If you answered “yes” in Question 45, please describe in detail, indicating dates, diagnoses and

any ongoing treatments or difficulties.

47.) Please list any allergies you have (medications, food, hay fever, dust, etc.) and your current

treatment for them (if any).

48.) Have you ever been diagnosed with, or treated for, alcoholism or any other drug-related

addiction? If so, please provide more details, including how long you’ve been in recovery, if

that’s the case.

49.) Do you have a temper? How often do you lose your temper? What provokes you?

50.) How do you deal with anger?

51.) How do you deal with someone who intimidates you?

52.) When was the last time you hit, punched, kicked, or threw something in anger? Please provide

details.

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Section IV: Your Chance to be Creative

53.) List three adjectives that best describe you.

54.) If you could hold any political office, what would it be and why?

55.) What is the accomplishment you are most proud of?

55a.) What are you most ashamed of, either now or in your past?

56.) Describe your perfect day.

57.) Who is your hero and why?

58.) List three (3) items you would take with you into the house if allowed and why?

59.) Have you ever been to a nude beach? If so, what was it like?

60.) Finish this sentence: “My life’s motto is…”

61.) If you could throw a surprise party to honor someone in your life that is deserving, who would it

be and why does this person deserve to be honored?

62.) What would you do if this show made you famous?

63.) What types of people would you choose to have living with you in the house?

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64.) What types of people would you NOT choose to live with you in the house?

65.) What would irritate you about living in a house with nine to eleven other people?

66.) What do you think would be the most difficult part of living in the house? Explain.

67.) Who is your favorite supermodel? …your least favorite? Explain.

68.) Do you have a strategy for winning the contest?

69.) Aside from the modeling contract, what do you hope to gain from being selected as the winner of

the show?

70.) Is there anything else you’d like to tell us about yourself and why you think you’d make a great

participant for this show and housemate? Try to differentiate yourself and be creative!

71.) Have you ever applied for and/or appeared on any other reality TV shows, dating shows or game

shows?

72.) How did you hear about the show?

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RELEASE AND WAIVER

Please Print Your Full Name: ____________________________

Please read, fill out, sign, and date the following:

I have listed below, to the best of my knowledge, (i) anyone I know or have known (including myself) who

has now, or has been in the past two years, an officer, employee, agent or representative of The CW television

network (the “Network”), CBS Corporation (“CBS”), Ten By Ten Entertainment (“TBTE”), Bankable

Productions, Inc. (“BPI”), Anisa Productions, Inc. (“Producer”), Pottle Productions, Inc. (“Pottle”), and/or any

of their respective licensees, assignees, partners, parents, or affiliated or subsidiary companies, and (ii) the

titles, jobs, and/or functions such persons have held or occupied:

I hereby acknowledge that: (i) I understand, satisfy, and agree to be bound by, the eligibility requirements for

AMERICA’S NEXT TOP MODEL (the “Program”); (ii) I have answered and will answer all questions posed

to me honestly and accurately; (iii) if any of the information that I have provided or will provide is found to

be false or incomplete, it may be grounds for dismissal from the Program selection process, and/or my being

dismissed as a Program participant, if previously selected as a participant; (iv) even if I meet the eligibility

requirements, the Network, Producer, Pottle, CBS, BPI, TBTE, and/or any of their respective licensees,

assignees, partners, parents, or affiliated or subsidiary companies have no obligation to conduct any initial

and/or follow-up interview with me, and/or select me as a participant; (v) even if I am selected as a

participant, the Producer has no obligation to produce the Program and the Network has no obligation to

broadcast it, even if it is produced; (vi) in the event that the show is cancelled, or not broadcast for any reason,

the Producer has no obligation to award any prize money; (vii) all of Producer’s decisions concerning

selection of the participants, the elimination of participants on the Program and winners in the Program are

final and not subject to challenge or appeal; and (viii) the Producer shall own and shall have no obligation to

return or maintain any materials submitted as part of my application whether or not I am or am not selected as

a participant.

By submitting this application, I hereby consent to the recording, use and reuse by Producer of my voice

(including, without limitation, my speaking and singing voices), actions, likeness, name, appearance and

biographical material (i.e., collectively “Likeness”) in any and all media now known or hereafter devised,

worldwide in perpetuity, in or in connection with the Program and the promotion and exploitation (in any

form or media) thereof. I agree that Producer may use all or any part of my Likeness, and may alter or modify

it regardless of whether or not I am recognizable. I further agree that the Producer exclusively owns any

application materials (videos, photos, etc.) that I may have provided in connection with my application for or

participation in the Program and any photos, video or recordings of any kind that Producer will make of me in

connection with the Program and my application therefor (collectively, the “Materials”) and all rights therein

and thereto including, without limitation, the right to use the Materials and my Likeness in any and all media

now known or hereafter devised worldwide, in perpetuity. Without limiting the foregoing in any way, I

further agree that the Producer may use my Likeness and the Materials in connection with any promotion,

publicity, marketing or advertisement for the Program or any exploitation of the Program of any kind. I grant

the rights hereunder whether or not I am selected to participate in the Program in any manner whatsoever. I

release the Producer, the Network, CBS, Pottle, TBTE, BPI, and/or any of their respective licensees, assigns,

parents, partners, subsidiaries or affiliated entities and each of the employees, agents, officers and directors of

the foregoing entities (collectively “Releasees”) from any and all liability arising out of the use of my

Likeness and/or the Materials or in connection with any part of my application process for the Program

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including, without limitation, any termination by me of any modeling, management or other representation

agreements. I agree not to make any claim against Releasees as a result of the recording or use of my

Likeness and/or the Materials (including, without limitation, any claim that such use invades any right of

privacy and/or publicity and any claims based on defamation or libel or false light). Without limiting the

foregoing in any way, to the degree that the Materials include any musical or literary compositions in which I

(partially or wholly) own, or to which I purport to (partially or wholly) own, the copyright or any publishing

rights, I hereby grant to the Producer, and have the complete, unfettered right to grant to the Producer, an

irrevocable, unlimited, perpetual, worldwide, royalty and payment-free license to use and reproduce such

Materials in the Program and in connection with any promotion, publicity, marketing or advertisement for the

Program or any exploitation of the Program of any kind, in any and all media now known or which may exist

in the future. I understand that the Producer makes no representation that such Materials will or will not be

used in any way. Any of the rights granted herein may be exercised by the Producer and their respective

authorized agents, licensees, contractors, partners, successors and assigns. I understand and agree that the

Network and Pottle are third party beneficiaries to this agreement, and I acknowledge and agree that my

performance of any obligations under this agreement is intended to benefit the Network and Pottle.

CHOICE OF LAW

This agreement shall be deemed to be entered into in Los Angeles County, California, and shall be

governed by and interpreted in accordance with the laws of the State of California applicable to

agreements executed and performed entirely within the State of California. Subject to the arbitration

provision below, any action, proceeding or litigation concerning this agreement or my appearance or

participation in the Program may only be brought in Los Angeles County, California, and I hereby agree

that the courts of Los Angeles County, California, shall have exclusive jurisdiction over me and the

subject matter of any such proceeding.

ENTIRE AGREEMENT

This agreement expresses the entire understanding between me and the Producer and replaces any and all

former and contemporaneous agreements, understandings or representations between me and the

Producer. No modification, alteration or amendment of this agreement will be valid or binding unless in

writing and signed by both me and the Producer.

RESOLUTION OF DISPUTES/BINDING ARBITRATION

THE PARTIES HERETO AGREE THAT ANY AND ALL DISPUTES OR CONTROVERSIES

(REGARDLESS, BY WAY OF EXAMPLE ONLY, WHETHER SUCH DISPUTES OR

CONTROVERSIES ARE BETWEEN PRODUCER AND/OR THE NETWORK, POTTLE OR ANY

OTHER TELEVISION NETWORK, ON THE ONE HAND, AND ME, ON THE OTHER HAND;

BETWEEN ANOTHER PARTICIPANT AND ME; OR BETWEEN ME AND THE PROGRAM

HOST) ARISING UNDER THIS AGREEMENT OR ANY OF ITS TERMS, ANY EFFORT BY ANY

PARTY TO ENFORCE, INTERPRET, CONSTRUE, RESCIND, TERMINATE OR ANNUL THIS

AGREEMENT, OR ANY PROVISION THEREOF, AND ANY AND ALL DISPUTES OR

CONTROVERSIES RELATING TO MY APPEARANCE OR PARTICIPATION IN THE

PROGRAM, SHALL BE RESOLVED BY BINDING ARBITRATION IN ACCORDANCE WITH

THE FOLLOWING PROCEDURE: EITHER (I) PRODUCER AND/OR NETWORK, ON THE ONE

HAND, AND I, ON THE OTHER HAND, SHALL MUTUALLY SELECT AN ARBITRATOR, WHO

SHALL BE A RETIRED JUDGE OF A STATE OR FEDERAL COURT OR (II) IF WE CANNOT

AGREE ON SUCH ARBITRATOR, PRODUCER AND/OR NETWORK ON THE ONE HAND, AND

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I, ON THE OTHER HAND, SHALL EACH SELECT ONE ARBITRATOR, WHO SHALL BOTH BE

RETIRED JUDGES OF STATE OR FEDERAL COURTS AND THOSE TWO ARBITRATORS

SHALL THEN SELECT A THIRD ARBITRATOR, WHO SHALL BE A RETIRED JUDGE OF A

STATE OR FEDERAL COURT. ALL ARBITRATION PROCEEDINGS SHALL BE CONDUCTED

UNDER THE AUSPICES OF THE AMERICAN ARBITRATION ASSOCIATION, UNDER ITS

COMMERCIAL ARBITRATION RULES, THROUGH ITS LOS ANGELES, CALIFORNIA

OFFICE. THE PARTIES HERETO AGREE THAT THE ARBITRATOR’S RULING, OR

ARBITRATORS’ RULING, AS APPLICABLE, IN THE ARBITRATION SHALL BE FINAL AND

BINDING AND NOT SUBJECT TO APPEAL OR CHALLENGE. THE PARTIES HERETO

FURTHER AGREE THAT THE ARBITRATION PROCEEDINGS, TESTIMONY, DISCOVERY

AND DOCUMENTS FILED IN THE COURSE OF SUCH PROCEEDINGS, INCLUDING THE FACT

THAT THE ARBITRATION IS BEING CONDUCTED, WILL BE TREATED AS CONFIDENTIAL

AND WILL NOT BE DISCLOSED TO ANY THIRD PARTY TO SUCH PROCEEDINGS, EXCEPT

THE ARBITRATOR(S) AND THEIR STAFF, THE PARTIES’ ATTORNEYS AND THEIR STAFF,

AND ANY EXPERTS RETAINED BY THE PARTIES. NOTWITHSTANDING THE FOREGOING,

NOTHING IN THIS PARAGRAPH OR IN ANY OF THE APPLICABLE RULES OF THE

AMERICAN ARBITRATION ASSOCIATION SHALL PREVENT PRODUCER, POTTLE OR THE

NETWORK FROM SEEKING PROVISIONAL RELIEF OUTSIDE OF ARBITRATION,

INCLUDING BUT NOT LIMITED TO EQUITABLE AND/OR INJUNCTIVE RELIEF, PENDING

THE ARBITRATOR’S FINAL DECISION.

MISCELLANEOUS

Without limiting the foregoing, any provision of this agreement that is invalid, illegal, or unenforceable in

any jurisdiction will, as to that jurisdiction, be ineffective only to the extent of such invalidity, illegality

or unenforceability, without affecting in any way the remaining provisions hereof in such jurisdiction or

rendering that or any other provision of this agreement invalid, illegal or unenforceable in any other

jurisdiction. Any laws that require or suggest that the interpretation of a document or agreement, or the

resolution of any ambiguities contained therein, should be resolved against the drafter of the document or

agreement, are hereby waived. No waiver by the Producer of any term or condition of this agreement will

be construed as a waiver by the Producer of any other term or condition; nor will any waiver by the

Producer of any default under this agreement be construed as a waiver by the Producer of any other

default. It is further understood and agreed that no failure or delay in exercising any right, power or

privilege hereunder shall operate as a waiver thereof, nor shall any single or partial exercise thereof

preclude any other or further exercise thereof or the exercise of any right, power or privilege hereunder.

The Producer, the Network and/or Pottle may freely assign, in whole or in part, any of their respective

rights or obligations under this agreement. I may not assign my rights and obligations under this

agreement.

I have signed this release on the _________ day of _____________, 201__

Signature: _________________________

Name (Please print or type): _________________________

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