*Required fields
*Name
Date of Birth (MM/DD/YYYY)
*E-mail
Address
City
State
Zip
Phone Number (Home)
Phone Number (Cell)
I wish to apply to represent Select One Amarillo Arlington Austin Beaumont Corpus Christi Collin Co. Dallas Del Rio East Texas El Paso Fort Worth Fort Bend Co. Galveston Co. Garland Harris Co. Houston Laredo Lake Jackson Lubbock Marshall Nacogdoches North Texas Northeast Texas Pearland Richardson San Antonio San Marcos South Texas Southeast Texas Stafford Sugarland Tarrant Co. Texarkana Travis Co. Tyler Victoria Waco West Texas
I certify that I reside in this area/city:
Pageants previously entered (titles, if any):
Name of High School or Middle School:
Classification / Grade :
GPA
School related extracurricular activities/ clubs/ sports/ organizations
Name of parent or guardian, if under 18:
Are you currently under any contracts? Select One Yes No
If you selected "Yes" above, please explain:
What is your platform, or what do you want to do with your title?
What is your talent? What type of talent would you perform in the pageant?
How did you hear about this pageant? Select One Miss Black USA Website Facebook Recruiter Local Pageant Poster or Flyer Current Contestant Former Contestant Search Engine Other
I authorize the verification of the information provided on this form. I certify that I am a single (unmarried) female, was born female gender, between the ages of 13 and 18, and I am eligible to compete for the title of Miss Black USA Talented Teen. You must be at least 13 and no older than 18 by August 1, 2010. Note: Your online application will not be processed without payment of the non-refundable application fee.
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*Date
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