Part I: About Me
Who is your current employer and occupation? (What job pays your bills now?)
What levels of education have you completed (please specify school and major):
High School, Some College, Professional Degree, Bachelors Degree, Masters Degree, Doctorate.
School(s): Major(s): Year Graduated:
What is the next milestone in your life if you do not make the show?
Do you work out? If so, what types of activities and how often? (Be as specific as possible)
What sports organizations have you been a member of? (i.e., High School; College; Minors; Professional; etc..., please list all that apply and the levels played)
Please circle those that apply: Married, Divorced, Boyfriend/Girlfriend, Single
How long have you been in your current relationship?
What would your friends say are your best qualities?
What would your friends say are your worst qualities?
What magazines/newspapers do you read?
How are you competitive in your every day life?
What do you think was the scariest stunt on a previous Fear Factor?
What pets do you own now, or have owned at any time in the past?
Have you had any experiences that have traumatized you? If yes, please explain:
What is your unique and personal motivation for wanting to compete on the show?
How would you use $50,000 in Fear Factor winnings?
Who do you live with and for how long?
Please list your last three jobs:
Do you have any military experience? Are you (active /reserve) military now? (Circle one) If so, please describe branch, rank, job, and dates of enlistment:
What conversation topics are "off limits" for you at a dinner party?
What is the most daring and dangerous thing you have ever done? Describe the circumstances:
If you were going to be in People magazine, what inside info about you would be put up next to your picture?
Describe your most embarrassing moment:
What is the weirdest thing about you?
If you had Aladdin's lamp and 3 wishes, what would you wish for? (Rule: you can't wish for money or more wishes).
1)___________________________________________________________________________________
2)___________________________________________________________________________________
3)___________________________________________________________________________________
Why?
What is your strategy to win the game? (We won't tell the others.)
How do you feel about opening up yourself and your life as an "open book" on national television?
Do you know anyone who has or is applying for the show Fear Factor? (if yes, please list their names).
Do you now or have you ever owned or appeared on any web sites? No/Yes (If yes, please explain and list sites):
What other reality TV shows have you applied for? List the shows and month/year:
Are you currently being considered for any other reality shows? If yes, please explain:
When will you NOT be available in 2004 and 2005 to come to LA for one week? Please specify conflict dates
Do you smoke? Yes_______ No_______ Sometimes_______
Can you swim? Yes_______ No_______ Not that well_______
What is your height and weight? Height:______________ Weight:______________
Part III: My Background Information
Have you ever been treated for any serious physical or mental illness(es) or had any serious injuries?
Yes_______ No_______
If yes, please describe in detail, citing dates, diagnosis and any on-going problems:
Are you on any medication that you must take on a regular basis?
Yes_______ No_______
If yes, please describe in detail:
Do you have any allergies?
Yes_______ No________
If yes, please describe in detail:
Have you ever been treated for stress-induced asthma, heart conditions, or high blood pressure?
Yes_______ No_______
If yes, please describe in detail, citing dates, diagnosis and any on-going problems:
By law, you must list television shows that you have appeared on. You may not appear on this show if you have appeared on any contest or game show within the past twelve months or appeared on two contest or game shows within the last five years. Even if you did not win anything, you must disclose all television appearances.
Show Network Approximate Air Date Role in Show Prizes Won
Have you ever written, contributed to, or been interviewed for any magazine or newspaper article, radio or television program, or written or contributed to any other print or media?
Yes_______ No_______
If yes, please describe your involvement:
Have you been asked by any individual or entity to submit this application?
Yes_______ No_______
If so, describe in detail that request and any compensation you may receive if you are chosen to appear on the show or participate in the application process.
Please list below, to the best of your knowledge, anyone you know or have known who is now, or has been in the past two years, an officer, employee, agent or representative of:
(a) National Broadcasting Company, Inc. ("NBC"), its licensees, assigns, parent (General Electric Co.), or affiliated or subsidiary companies (e.g., NBC Studios, Inc.) or any affiliated television station, or any television station or channel that broadcasts the Program.
(b) Pulse Creative, Evolution Film & Tape, Inc., Lock and Key Productions, Endemol Entertainment USA, Inc. or any of their respective licensees, assigns, parents, or affiliated or subsidiary companies or any other person or entity involved in the development, production, distribution or other exploitation of Fear Factor or any variation thereof.
(c) Any sponsor of Fear Factor or its advertising agency.
(d) Any person or entity supplying prizes or services to Fear Factor.
Have you ever been charged with any crimes, including a misdemeanor or a felony?__________
If yes, please explain briefly:
Have you ever been convicted of any crimes, including a misdemeanor or a felony?___________
If yes, please explain briefly:
Have you ever had a temporary or permanent restraining order against you, or an application for a temporary or permanent restraining order against you?______________________________________________________________________________
Is there any pending litigation against you?___________________________________________________________________
Have you ever been diagnosed with alcoholism or drug addiction? If so, please describe in detail and indicate how long you've been in recovery.
_______________________________________________________________________________________
ELIGIBILITY REQUIREMENTS
1) You must be a legal resident of the United States.
2) You must be at least 21 years of age.
3) You must not be a candidate for public office and must agree not to become one until after the initial broadcast of the programs in which you appear, if selected as a participant.
4) You must not have appeared in more than two (2) television competition or game shows within the last five (5) years from the tape date of the program in which you may appear. In addition, you may not have appeared on more than one (1) television competition or game show within the past twelve (12) months from the tape date of the program in which you may appear (regardless of whether such appearance has been broadcast or cablecast).
5) Neither you nor any member of your immediate family or anyone living in your household may be currently employed by or have been employed within the last two (2) years by, or be a close acquaintance of anyone employed by or employed within the last two (2) years by, any of the following:
(a) National Broadcasting Company, Inc. ("NBC"), its licensees, assigns, parent (General Electric Co.), or affiliated or subsidiary companies (e.g., NBC Studios, Inc.) or any affiliated television station, or any television station or channel that broadcasts the Program.;
(b) Pulse Creative, Evolution Film & Tape, Inc., Lock and Key Productions, Endemol Entertainment USA, Inc. or any of their respective licensees, assigns, parents, or affiliated or subsidiary companies or any other person or entity involved in the development, production, distribution or other exploitation of Fear Factor or any variation thereof.;
(c) Any sponsor of Fear Factor or its advertising agency; or
(d) Any person or entity supplying prizes or other services to Fear Factor.
6) If selected as a participant you must execute waivers and release agreements required by NBC or the production company.
7) You will need to be available for approximately one week to the production and be willing to travel to one or more locations within the United States.
8) If selected as a semi finalist, you must be willing to submit medical information to the production and submit to a medical examination, psychological examination, and background check.
Please read, sign and date the following acknowledgement:
I hereby acknowledge that: (i) I have read and agree to be bound by the eligibility requirements; (ii) I have answered the previous questions honestly and accurately; (iii) if any of the above information is found to be false or incomplete this will be grounds for dismissal from the Fear Factor contestant selection process, and/or from the Fear Factor contest, if selected; (iv) even if I meet the eligibility requirements, Producers have no obligation to interview me, and/or select me as a contestant; (v) even if I am selected as a contestant, Producers have no obligation to conduct the contest and NBC has no obligation to broadcast it, even if conducted; (vi) in the event the show is cancelled, Producers and NBC have no obligation to award any prize money; (vii) all decisions by Producers concerning selection of the contestants is final and not subject to challenge or appeal; and (viii) Producers have no obligation to return any materials submitted by me as part of the application whether or not I am selected as a cast member.
______________________________________________________________________________
Signature Date
Please sign and date the following NAME AND LIKENESS RELEASE AND TRANSFER OF RIGHTS:
By submitting the application I hereby consent to the recording, use and reuse by the Producers of the Program (defined below), NBC West, LLC, Endemol Project, Inc., Endemol Entertainment USA Inc., Lock and Key Productions, Pulse Creative, Evolution Film & Tape Inc., and any of their respective licensees, assignees, parents, subsidiaries, or affiliated entities and each of the respective employees, agents, officers and directors (collectively "Releasees") of my voice, actions, likeness, name, appearance, biographical material, and any information contained in my application to be a contestant in the Program or in any materials submitted by me in connection with my application (collectively "Likeness") in any and all media now known or hereafter devised, worldwide in perpetuity, in or in connection with the reality-based television series currently entitled "Fear Factor" (the "Program"). I agree the Releasees 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 Releasees exclusively own all right, title, and interest (including, without limitation, all copyrights) in and to any video that I have provided in connection with my application and any other materials that I have provided or may provide in connection with the Program (the "Materials") including, without limitation, the right to edit, alter or modify the Materials and to use all or part of the Materials and my Likeness in any and all media now known or hereafter devised worldwide, in perpetuity. I further agree that Releasees may use my Likeness and the Materials in connection with any promotion, publicity, marketing or advertisement for the Program. I grant the rights hereunder whether or not I am selected to participate in the Program in any manner whatsoever. I release Releasees from any and all liability arising out of its recording or use of my Likeness and/or the Materials. 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). I understand that I will not be paid any money for giving Releasees these rights, or for signing this agreement.
I have signed this release on the ____________ day of _______________________, 20_____.
Signature_________________________________________________________
Name (Please print or type)___________________________________________
Thank you for your time and effort in completing the form.
Don't forget to attach a photocopy of your Driver's License. Good Luck!
|
