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The MISS T•:EN USA® & MISS USA P•!ltc•nUl® 11rc part of the Miss Univcr#C Os,tanization. whieh is• Don•ld J. Trump 11nd NBCUnivcrs11I Mcdi110 1,1,C joint venture. The Connecticut. lndi11n110 Pcnn11ylYlllni11.0 Vermont & West Viri(ini• Sbltc Prcliminar,. Pa,tc11nt1111.rc independently conducted and produced h)' Sanders & Asliociatcli0 lne •• under liccn.c from Miu Uni-1'$C0 LP •• l,LLP

MISS USA .. and MIS.liil T•:•:N USA._ and all varianUl thereof. 11nd the -woman with Stars-1.oll(o and crown dcsil(n• arc all rcll(it1tcrcd tradcmarlu and copyrighu of Miss Universe 1-P •• LI.LP Mcdia, l,I.Cjuint venture.

Enclosed are your Official State Pageant Forms! Please return required forms to the Pageant Office by fax, email or mail.

Be sure to sign the necessary documents.

1. Contestant File: Each participant has a “Contestant File” which is kept in our office. It must be completed priorto pageant weekend registration and contains all paperwork, photos, sponsorship information and spotlight pages.

2. Paperwork/Documents: The following is a description of the paperwork and documents needed to finalizeyour Contestant File. All forms can be found on your state website. You can also refer to the ‘Online Instructions’page of your Acceptance Handbook. Simply call the pageant office for the case-sensitive password to access theforms. Always keep a copy of any form or document you turn in to the pageant office for your own records.

Pageant Registration- Personal Information Form- The front of this form contains your basic contact information and the back is an application agreement that must be signed.

Biography- Do not submit attachments with this form - be sure to use our form exclusively! Your biography will be used throughout pageant weekend. Parts of it will be read on stage during the swimsuit and evening gown competition; the judges will have a copy to refer to during interview competition and the Top 5 Finalist on-stage interview questions will be taken from this biography. This bio is the first opportunity the judges have to form an opinion of you; it must be neatly typed and contain general information. Avoid long wordy answers and give responses that will catch the judge’s attention.

Medical Form- This will inform us of any medical conditions or allergies you may have.

Sponsor List- Please print your full name and sponsor list exactly how you want them to printed in the program book and on our website.

Sponsor Receipt- Your sponsors may like to have a receipt for their records.

Birth Certificate- You will need to provide us with a copy of your birth certificate. Do not the send the original!

Two Proofs of Residency (POR)- Each contestant needs to prove her state residency. Please review the “Proof of Residency” page in your Acceptance Handbook to clarify what official forms and documents are acceptable.

Contestant Contract- It is important that you read and initial each page, and that you and your parent or guardian sign and date the contract. (Sent Separately)

3. Program Book/Website Photograph: You will need to submit one official color photograph that will be usedboth on our website and in our program book. Your head shot should be professionally taken. (It can be a schoolphoto.) It must be a COLOR photograph showing you in a head-and-shoulder pose. You can send us the actualphoto, an image on CD, or a digital image sent to photos@pageantassociates.com (a 300 dpi jpeg). Pleaseinclude your name and the pageant you are entering with the photo in the email (Example: Jane Smith –PA USA Pageant). The photo must be at least a 3x5 image of a printable quality. Do not send an ink jet print asthey do not reproduce well in our program. If you have questions about what qualifies as an appropriate photo,simply call our office and we’ll be happy to help.

4. Deadlines: Now that you know everything that is required, it is important to establish a strategy to accomplishyour goals, complete your paperwork, submit your entry fee and select your wardrobe in a timely manner. Startpreparing now so you can relax closer to the pageant! Do not hesitate to call or email the pageant office if youneed deadline dates clarified.

5. Final Packet: Closer to pageant weekend you will receive your final packet that will include your PageantPhoto and Video order form, Weekend Schedule, Rules & Regulations during Pageant Weekend and much more!

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) _______

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 _________________________________________________________

_______________________________________________________________________________________________

Must be at least 14 but under 27 years of age on this date

E-mail Address: _____________________________________________ @ _________________________________

Please list occupation or name of school if student: _____________________________________________________

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.

a) Are you currently and will you continue to be a permanent resident of the state for which you are applyingto compete in, for the full 6 month period prior to the state pageant?

b) If no to the above, are you an out-of-state resident who is attending and has completed on full-semester at a collegeor 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, LLCd/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?

Explain:____________________________________________________________________________

e) Have you ever been charged with the admission of a crime, appeared in public or photographed in a state of full orpartial 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…)

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)

Please Circle One

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

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

Miss Connecticut USA® PageantMiss Indiana USA® PageantMiss Pennsylvania USA® PageantMiss Vermont USA® PageantMiss West Virginia USA® Pageant

Miss Connecticut Teen USA® PageantMiss Indiana Teen USA® PageantMiss Pennsylvania Teen USA® PageantMiss Vermont Teen USA® PageantMiss West Virginia Teen USA® Pageant

2017 Pageant Registration - Personal Information Form Check Applicable

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® PageantIndependently produced by Sanders & Associates, Inc.

Please Read Very Carefully!

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: ________________

BIOGRAPHY IN CONNECTION WITH MY STATE PAGEANT, INCLUDING USE IN PROMOTIONAL AND ADVERTISING MATERIAL.

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 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 MISS UNIVERSE ORGANIZATION, and I agree to abide by that determination both as to myself and other applicants.

14. I agree to abide by all the rules of the MISS (STATE) TEEN USA® Pageant or the MISS (STATE) USA® Pageant and the MISS USA® Pageant or MISS TEEN USA® Pageant now in effect or as announced from time to time hereafter.

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 (STATE) TEEN USA® or MISS (STATE) USA® is under the sole and complete discretion of the State Director of the MISS (STATE) TEEN USA® or MISS (STATE) USA® Pageant.

16. I agree to permit my photograph, voice recording, and name to be used without charge for all publicity and commercial purposes and any telecasts of the state and national pageants.

17. I agree that, if I win or succeed to the title of MISS (STATE) TEEN USA® or MISS (STATE) USA®, the terms of this Application and Agreement, including, without limitation, Sections 17 through 22, inclusive, shall continue to be binding upon me, and that any breach 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 to equitable relief and the costs and expenses of obtaining the same, including reasonable attorneys’ fees.

18. I understand and agree that if I win or succeed to the title of MISS (STATE) TEEN USA® or MISS (STATE) USA®, as one of my obligations, I will go to and stay in the host city during the time required for me to appear in the MISS USA® Pageant or MISS TEEN USA® Pageant.

19. I understand and agree that if I win or succeed to the title of MISS (STATE) USA® or MISS (STATE) TEEN USA®, all decisions concerning my preparation for the MISS USA® or MISS TEEN USA® Pageant shall be made by my State Director. To this end, and by way of example and not limitation, I agree (i) to utilize exclusively the services of the staff of the MISS (STATE) USA® Pageant or MISS (STATE) TEEN USA® Pageant, and each pageant sponsor in connection with my preparation for the MISS USA® or MISS TEEN USA® Pageant; (ii) to wear, during the evening gown competition of the MISS USA® Pageant or MISS TEEN USA® Pageant, a gown provided by the pageant sponsor; (iii) not to engage or continue the services of or otherwise consult with (for monetary consideration or otherwise) any person, firm or other entity providing services in competition with a pageant sponsor; or (iv) not to engage or continue to use or consult with any interview, stage presentation, or other pageant coaches. I 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 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 MISS (STATE) TEEN USA® Pageant or MISS (STATE) USA® Pageant, I have not and will not engage in any activities which, if disclosed to the public, would bring or tend to bring, myself or the State Pageants into disrepute, ridicule or contempt.

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 or obligations hereof shall, at the option of the State Director of the MISS (STATE) USA® Pageant or MISS (STATE) TEEN USA® Pageant, result in all or any of my disqualification, loss of title, and my obligation to return immediately any and all prizes awarded.

22. I understand and agree that if I win or succeed to the title of MISS (STATE) USA® or MISS (STATE) TEEN USA®, I will not permit the use of my name, photograph, image, or title as MISS (STATE) USA® or MISS (STATE) TEEN USA® by anyone without the prior written consent of my State Director.

RELIANCE BY PAGEANT; EFFECT OF SIGNATURE

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 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 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 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 (STATE) TEEN USA® Pageant.

I hereby apply as an entrant in the 2017 MISS (STATE) USA® Pageant or 2017 MISS (STATE) TEEN USA® Pageant (together, the “State Pageants”) and for the opportunity to compete in the 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:

REPRESENTATIONS:

1.MISS: I will be at least eighteen (18) and under twenty-seven (27) years of age on January1, 2017.

2.TEEN: I will be at least fourteen (14) and under nineteen (19) years of age on January 1, 2017.

3. I am not married, have never been married, and have never had a marriage annulled. I have never given birth to a child and am not now pregnant nor am I a parent of an adopted child. If any of these conditions change, I will notify the State Director immediately, and I understand that this may affect my eligibility.

4. I have never participated in a previous national MISS USA® Pageant (for Miss (STATE) USA contestants) or MISS TEEN USA® Pageant (for Miss (STATE) Teen USA contestants).

5. I have not participated and will not participate in any other state’s preliminary pageant (including any pageant preliminary to another state pageant) to the 2017 MISS USA® Pageant or the 2017 MISS TEEN USA® Pageant, including the District of Columbia.

6. Prior to the date of this Application and Agreement, I have not been engaged in any activities which, if disclosed to the public, would bring or tend to bring myself or the State Pageants into disrepute, ridicule, or contempt. I am in good health and of good moral character.

7. I am recognized medically and legally as a female in the United States and a citizen of the United States and at least one of the following is true: (a) I now reside and have resided in (STATE) as my 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 which I have entered (although I may have attended college or university elsewhere); or (b) I have resided in (STATE) as a full-time student at a college or university for one entire 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 (STATE) as a full-time student (although I may have spent or be spending the summer in another state). 8. Neither I nor any member of my immediate family or anyone living in my household is currently employed by or has been employed within the last two (2) years by, or is a close acquaintance of anyone employed within the last two (2) years by any State Director in the MISS USA® and/or MISS TEEN USA® pageant system or any company or enterprise that the State Director may own or control, IMG Universe, LLC d/b/a The Miss Universe Organization (“Miss Universe”), IMG Worldwide, LLC, and their respective parents, subsidiaries, affiliates, and others (collectively, “the Parties”), or Ernst & Young. . (IF YOU OR ANY MEMBER OF YOUR IMMEDIATE FAMILY IS EMPLOYED BY ANY OF THE FOREGOING OR ANY FIRM OR CORPORATION CONTROLLED OR AFFILIATED WITH ANY OF THEM, THEN YOU MUST NOTIFY YOUR STATE DIRECTOR IMMEDIATELY IN WRITING, SO THAT YOUR ELIGIBILITY MAY BE DETERMINED.)

AGREEMENTS APPLICABLE TO ALL CONTESTANTS:

9. I agree that if I win or succeed to the title of MISS (STATE) USA® or the MISS (STATE) TEEN USA®, I will participate in the MISS USA® Pageant or MISS TEEN USA® Pageant, as the case may be, and abide by all the rules and regulations governing that pageant. If I win the MISS USA® Pageant, then I agree to participate in the MISS UNIVERSE® Pageant and abide by the rules and regulations governing that pageant.

10. I understand that the sponsorship requirement is due in full prior to the commencement of the state pageant and agree that I am free to withdraw from the State Pageants at any time prior 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 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 entitled to a refund or to transfer to another contestant any fee or sponsorship money, either in full or in part, that I or my sponsors have paid.

11. I agree that if I win or succeed to the title of MISS (STATE) USA® or MISS (STATE) 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.

12. I HEREBY RELEASE, UNCONDITIONALLY AND FOREVER, ANY CLAIM AGAINST THE STATE PAGEANTS, SANDERS & ASSOCIATES, INC., THE MISS UNIVERSE ORGANIZATION, AND THEIR RESPECTIVE PARENTS AND AFFILIATED OR RELATED COMPANIES AND OTHER RESPECTIVE OFFICERS, DIRECTOR, PARTNERS, EMPLOYEES, AGENTS AND ASSIGNS, WHICH I MAY HAVE BY VIRTUE OF MY PARTICIPATION IN MY STATE PAGEANT OR BY ANY USE OF MY NAME, LIKENESS, VOICE, AND/OR

(Parent /Guardian signature is REQUIRED if applicant is under 18 years of age. Please include your deposit when submitting this form.

Hometown: Age: Eye Color: Three Words that best describe you:

Name

Height:

For Office use only:

Education:

High School

College

Other

(Note whether you are attending, have attended, current grade, graduated, etc.)

Your career ambition is:

Your Occupation and Employer:

Occupation

Employer

Honors and Awards:

Your favorite hobbies are:Your one strongest talent is:

School & Community Activities:

What is your most vivid childhood memory?

What personal achievement are you the most proud of?

What social cause means the most to you and why?

How do you see your life in 10 years?

The most unusual thing you have done is:

The most unusual thing about you is:

First:

Middle:

Last:

(If you chooseto use it)

Do not include state

©Sanders & Associates, Inc. www.pageantassociates.com

SANDERS & ASSOCIATES, INC Independent producers of the MISS USA and MISS TEEN USA state preliminary pageants for

Connecticut, Indiana, Pennsylvania, Vermont and West Virginia under license by The Miss Universe OrganizationMEDICAL CERTIFICATE & RELEASE FORM

CONTESTANT NAME: ____________________________ EMERGENCY CONTACT: ______________________________

INSURANCE COMPANY: ______________________________ POLICY NUMBER: _________________________________

I hereby attest to the fact that I am presently in good physical condition and have no known health restrictions, which would limit my active participation in the pageant.

Medical Information:

List any ongoing medical conditions for which you are currently being treated or taking medication:

__________________________________________________________________________________________

List any medication you are currently taking:

__________________________________________________________________________________________

List any allergies to medications (e.g. penicillin):

__________________________________________________________________________________________

List any serious food allergies:

___________________________________________________________________________________________

Do you have any of the following conditions: (check only if applicable)

Epilepsy ____ Diabetes _____

Asthma ____ High Blood Pressure ____

Other (please specify)__________________________________________________________________

PARENTAL/CONTESTANT CONSENT FOR MEDICAL DIAGNOSIS, TREATMENT, BILLING OF INSURANCE AND

RELEASE OF LIABILITY (Parental signature needed for minors and delegates who are on their parents Insurance)

I (we) hereby consent to allow Sanders & Associates, Inc., and staff to select a hospital, clinic, or other medical facility that shall be authorized to diagnose and treat ________________________________ for any medical problem that may occur during her stay at the state preliminary pageant. In addition, I (we) hereby give permission to those granting services to bill our Insurance Company listed for any and all services listed. I (we) agree that by participating: 1. There are inherent risks of injury. 2. I (we) knowingly assume those risks and agree to indemnify and hold harmless, The Miss Universe Organization and Sanders & Associates, Inc., for all injuries sustained, except those caused by theproducer’s sole negligence.

______________________________________ __________________________________ Signature of contestant Date Signature of Parent/Guardian Date

______________________________________ _______________________________________ Print contestant’s name Print Parent/Guardian’s name

SPECIAL NOTES!

1.Have all checks written to:

Pageant Associates2.

Type or print your name and hometown exactly as you want them to appear in the program book.

3.Type or print your list of sponsors exactlyas you want them to appear in the program book.

If you have questions, call the Pageant Office at1-724-785-4648

FINAL SPONSORSHIP LIST FORMFOR PROGRAM BOOK

Please type or print neatly the information below.

First, list your name and hometown exactly as you want it printed in the official program book.

Second, list the names of up to 20 sponsors in your order of preference. You may have one sponsor or many sponsors, but keep in mind that we can list only 20 individuals and/or businesses with your photo in the program book.

Some helpful tips: For Business Sponsorships, list the business name -- not the name of the individual you contacted. Also, if many of your family members and friends participate, you may wish to list “Family & Friends” instead of individual names.

If you find that, even by grouping several of your sponsors under “Family & Friends,” you still have more than 20 you want to list, we recommend that you consider listing additional sponsors in an optional full- or half-page Spotlight Page (full-page: $350.00; halfpage:$250.00). Not only does the Spotlight Page provide you with space to list more sponsors, it is an excellent way to gain additional exposure for yourself in the program book as well.

NAME: __________________________________ HOMETOWN: ___________________________

SPONSORSPlease be complete and accurate so that each sponsor will receive proper recognition.

NAME: _______________________________________

NAME: _______________________________________

NAME: _______________________________________

NAME: _______________________________________

NAME: _______________________________________

NAME: _______________________________________

NAME: _______________________________________

NAME: _______________________________________

NAME: _______________________________________

NAME: _______________________________________

NAME: _______________________________________

NAME: _______________________________________

NAME: _______________________________________

NAME: _______________________________________

NAME: _______________________________________

NAME: _______________________________________

NAME: _______________________________________

NAME: _______________________________________

NAME: _______________________________________

NAME: _______________________________________

YOUR AGE AS OF SUNDAY OF YOUR PAGEANT WEEKEND: _______

Sponsor Receipt

This receipt acknowledges a donation of $______________ from ___________________________, (Amount) (Sponsor)

for _________________________ to use toward the sponsorship fee required to be a contestant in (Contestant Name)

the 2017 ________________________________Pageant. (State Pageant you are competing in)

The businesses, friends and family members contributing to the sponsorship fee may be listed in the program, if requested. (The sponsor’s name must be spelled correctly and provided to the Pageant Office to assure accurate recognition.)

Thank you greatly for your time and support.

_____________________________________ ______________________________ (Print Contestant’s Name) (Date)

_____________________________________ (Contestant’s Signature)

***************************************************************************************************

Sponsor Receipt

This receipt acknowledges a donation of $______________ from ___________________________, (Amount) (Sponsor)

for _________________________ to use toward the sponsorship fee required to be a contestant in (Contestant name)

the 2017 ____________________________Pageant. (State Pageant you are competing in)

The businesses, friends and family members contributing to the sponsorship fee may be listed in the program, if requested. (The sponsor’s name must be spelled correctly and provided to the Pageant Office to assure accurate recognition.)

Thank you greatly for your time and support.

_____________________________________ ______________________________ (Print Contestant’s Name) (Date)

_____________________________________ (Contestant’s Signature)

The MISS USA® and MISS TEEN USA® Pageants are part of the The Miss Universe OrganizationMISS USA® and MISS TEEN USA® and all variants thereof, and the “Woman with Stars” Logo are all registered trademarks and copyrights of The Miss Universe Organization

CREDIT CARD - SPONSORSHIP PAYMENT OPTION

For your convenience, we accept most major credit cards for all or part of your sponsorship fee. Simply complete the form below, detach and mail it to the Pageant Office with your required paperwork. The credit card account will be charged the day it is received. Please note, the credit card statement will reflect the payment as being

made to PAGEANT ASSOCIATES. Remember, sponsorship fees are non-refundable. We hope this service may be of assistance to you. Good luck in your final preparations.

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SANDERS & ASSOCIATES, INC. PLEASE COMPLETE OUR CREDIT CARD PAYMENT FORM

Pageant contestant's name: ________________________________________________

Address of the contestant:

_________________________________________

_________________________________________

The amount of sponsorship to be charged to the credit card listed below is:

$_____. ___

TYPE OF CREDIT CARD: (CHECK ONE) VISA____ MC ____ DISCOVER ____ AMEX ____

NAME OF CARDHOLDER: ___________________________________ PHONE #: ________________________________

ADDRESS OF CARDHOLDER: ___________________________________________________________________________

CARD NUMBER: _________________________________________________EXP. DATE: _______________________________

SIGNATURE OF CARDHOLDER: _______________________________________________________________________________

REMEMBER

PAYMENT WILL SHOW ON THE CREDIT CARD STATEMENT AS BEING MADE TO

PAGEANT ASSOCIATES.