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Official Application Miss Jacksonville / Miss First Coast Scholarship Pageant 2006
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| Full Name:
_________________________________________________________________________
(Full and Proper Name, put any nickname in
"quotes")
Other Name: _______________________________________________________________________ (As You Wish For It To Appear In The Program Book) Social Security Number: _____________________ Date of Birth: __________________________ Age: ______________________________ (As of date of competition in Local Pageant: 12/3/05) (Please attach a copy of your birth certificate.) Permanent Home Street Address: __________________________________________________________________________________ City, State, Zip: __________________________________________________________________________________ Phone Numbers (home, work, school, cell): ____________________________________________ ____________________________________________________________________________________ Email Address: ______________________________________________________________________ (if it is for a family member who can give you messages, please indicate who's email it is)Mailing Address (if different from above) (or School address if out of town in school): ______________________________________________________________________________ City, State, Zip: _____________________________________________________________________ Education: High School _____________________________________________________________ (Name of School) (Date Graduated) Class in High School (Fresh, Soph, Jr, Sr?): ____________________________________________ College: ___________________________________________________________________________ (Name of School) (Degree Sought)Years Attended: ____________________ Class this coming September 2005: ________________ Graduate School: ___________________________________________________________________ (Name of School) (Degree Sought) College Major:______________________________ Declared Minor: _______________________ Scholastic Honors: __________________________________________________________________ ____________________________________________________________________________________ Scholastic Ambition: ________________________________________________________________ ____________________________________________________________________________________ Career Ambition: ___________________________________________________________________ ____________________________________________________________________________________ Other Accomplishments: ____________________________________________________________ ____________________________________________________________________________________ Other Interesting Information, Hobbies, Activities, Fun Stuff?: ___________________________ ____________________________________________________________________________________ What type of talent will you present? __________________________________________________ (You need not give the exact title of your talent presentation here. Merely indicate if you will dance [ballet, tap, etc.], gymnastics, sing [classical, popular, etc.], play a musical instrument [piano, violin, etc.], comedy reading, dramatic skit, etc.) Special training in music, drama, dance, art, other? ___________________________________ ___________________________________________________________________________________ Employment Experience: ____________________________________________________________ Father’s Name & Occupation: ________________________________________________________ Mother’s Name & Occupation: _______________________________________________________ Names, Ages of Brothers and Sisters: _________________________________________________ Other interesting facts about yourself or family: ________________________________________ ___________________________________________________________________________________ The Miss America Organization encourages the young women who participate in the program to become involved in their communities and to speak out on issues of concern to them, their community and the nation (your platform). If selected the winner of this competition, what issue would you choose to focus on during your year of service? Does your platform have an official title? ____________________________________________________________________________________ ____________________________________________________________________________________ Give COMPLETE name of other local or state pageant titles awarded and if you completed your year of service. ____________________________________________________________________________________ ____________________________________________________________________________________ I certify that the information on this application is true and correct to the best of my knowledge. _____________________________________ - Contestant's Signature _____________________________________ - Parent's Signature _____________________________________ - Date _____________________________________ - Executive Director's Signature _____________________________________ - Date/Time Received Return this application form to the Pageant: 817 Willow Branch Avenue, Jacksonville, FL 32205, (904) 384-3578
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