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First Name:*

Middle Name:

Last Name:*

Nickname:

Have you ever legally changed your name, if so what names and why:

Gender:

D.O.B:

Contact Information

Address:

City:

State (Province):

Zip (Postal) Code:

Home Phone:

Work Phone:

Mobile:

Email:*

Website:

Facebook:

Tik Tok:

Instagram:

Twitter:

Other Social:

Hometown City:

Current City Residence:

Closest Airport:

Emergency Contact:

Relationship:

Phone:

Education / Employment Information

Education Completed:

School Attended:

Degree:

Occupation:

Time at current job:

Show Questions

When was your last relationship?:

How many serious relationships have you been in?:

How long was your longest relationship?:

Why did that relationship end?:

What is the best part of being in a relationship?:

Have you ever been engaged?:

Have you ever been married? If yes, when was the divorce finalized?:

Do you have any kids? If yes, please list names and ages::

Are you genuinely looking for a long-term relationship? Why?:

Why are you currently single?:

What avenues have you used to find dates? IE: set-ups,internet, singles functions etc.:

Do you currently belong to any dating networks? IE: match.com, eharmony, J date etc. If yes, please lets which ones and how long you have ben a member.:

What are you currently doing to find a relationship?:

What are absolute turn-offs for you in a member of the opposite sex?:

Describe your ideal romantic partner:

What is the most romantic thing you have ever done for someone you were dating?:

Do you think it is possible to find love on TV? Please explain.:

Will you only seriously date/consider relationships with people of specific ethnic persuasions? If so, which ones?:

Will you only seriously date/consider relationships with people of specific religious beliefs? If so, please explain in detail (not just - must believe in god).:

Are you aggressive or passive when it comes to finding a mate? Please explain.:

Are you competitive when it comes to love? Please explain.:

What would be your strategy for finding love AND winning the game?:

Would you be willing to manipulate others and "play the game" in order to connect with the partner of your choice? Please explain.:

What are your hobbies?:

Do you consider yourself competitive? Explain.:

What sports do you like to watch/play?:

How would your best friends describe you?:

What is the most extreme outdoor experience you have ever had?:

What do you do to keep in shape?:

Have you ever competed in an individual or group sport? If so, what sport and when?:

What is your favorite vacation spot?:

Do you have any tattoos or piercings? If so, please describe them.:

What are you afraid of (heights, snakes, earthquakes, etc.)?:

Describe your perfect day.:

In how many states have you lived? Please list all.:

What is the most exotic destination you have visited outside the country and why did you choose to visit there?:

Have you ever lived in any other countries? If so, where and when?:

Are you a camper? If so, what kind of camping do you normally do? IE: campground, tents, off trail camping, etc.:

Have you ever been a performer or participant on televisions, radio, or film? If so, please explain.:

Have you ever applied for an other dating/reality shows in the past year? If so, please explain.:

Are you currently being considered for any other reality shows? If so, which ones?:

Have you ever been detained or arrested whether charges were laid or not? Please explain.:

Have you ever been convicted of a crime? Please explain.:

Have you ever been or are you currently involved in litigation? Please explain.:

Have you ever had a restraining order issued against you or have you issued a restraining order against another person? Please explain.:

How easily can you take off from work if you are required to travel to locations outside of your city for several weeks?:

Please indicate below any schedule conflicts you may have between Feb 20 2012 and March 20, 2012.:

Please indicate the name of the producer who is handling your city. If we are not traveling to a city near you please write the name of the skype producer.:

Release Waiver

ELIGIBILITY REQUIREMENTS:

1. You must be either a U.S. citizen or a legal U.S. resident, by the time production begins on the "Love in the Wild" (the "Program").

2. You must be at least 21 years of age as of February 1, 2012.

3. You must have a valid United States Passport, or a United States Passport (or, if you are not a U.S. Citizen, a valid passport from your country of origin) that is valid as of January 1, 2012 and through and including December 31, 2012.

4. You must not be a candidate for public office and must agree not to become one until one (1) year after the initial exhibition of the episodes of the Program in which you appear, if selected as a participant for the Program.

5. You will need to be available for the production dates, tentatively scheduled to be from February 22, 2012 through March 25, 2012, and be willing to travel to various locations which may be located within or outside of the United States (including foreign countries) as part of production.

6. You may not participate in the Program if your participation would create impropriety or the appearance of impropriety. In making this determination, Lock and Key Productions, ("Producer") and NBCU (as defined below) will consider whether you or any member of your immediate family or anyone living in your household is or has been within the last two (2) years an employee, officer, director or agent of any of the following:

(a) NBCUniversal Media LLC ("NBCU") or any television production company, network, station or distributor owned and operated by NBCU;
(b) Producer, Endemol USA Inc., and their parent, subsidiary and affiliated companies, or any other person or entity involved in the development, production, distribution or other exploitation of the Program or any variation thereof and each of their respective officers, directors, agents, representatives, employees, successors, assignees, and licensees;
(c) Any sponsor of the Program or its advertising agency; or
(d) Any person or entity supplying prizes or other services to the Program.

Please disclose any such relationships below; if "none," write "none".
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

In addition, Producer and NBCU reserve the right, but are not obligated, to disqualify or render ineligible any person whom Producer and/or NBCU determine, in their sole discretion, is sufficiently connected with the production, administration, casting, judging, or distribution of the Program, such that his or her participation in the Program could create the appearance of impropriety. Such decisions shall be final and are not subject to challenge or appeal.

RELEASES/REPRESENTATIONS, WARRANTIES AND ACKNOWLEDGEMENTS:

7. If you are selected as a potential participant ("Participant") for the Program, you must execute waivers and release agreements, including, but not limited to, a longer form applicant agreement and other agreement(s) as required by Producer, NBCU, or their licensees, successors or assigns.

8. Your participation in the Program, if selected, is conditioned upon your submission to, if requested by Producer, physical examinations by medical professionals selected by and paid for by Producer, and the certification by such medical professionals that you meet all of the physical requirements for participation in the Program. In addition, you must be willing to provide any requested medical information to Producer and/or NBCU, and you must be willing to submit to any psychological examination(s) and any background check(s), if and as requested by Producer. You hereby authorize Producer and any person or entity designated by Producer to conduct physical examinations and/or psychological evaluations of you as required by Producer. You further authorize the individuals conducting such examinations and/or evaluations of you to disclose to Producer, NBCU, and their respective representatives all information about you obtained in connection with such examinations and/or evaluations, and authorize Producer to utilize such information in selecting Participants for the Program.

9. You hereby give the following representations, warranties, acknowledgements, consents and releases:

(a) By signing below, you hereby represent, warrant, acknowledge, and agree that: (i) you have read and you meet and agree to be bound by the eligibility requirements set forth in this Application; (ii) you have completed this Application honestly and accurately; (iii) if any of the information in this Application is found to be false or incomplete, it will be grounds for dismissal from the participant selection process and/or from the Program (if selected); (iv) even if you meet the eligibility requirements, Producers have no obligation to interview you and/or select you as a participant; (v) you agree to keep strictly confidential all information about the Program that you acquire during the participant selection process and/or during your participation in the Program (if applicable); (vi) even if you are selected as a participant, Producers have no obligation to produce the Program and there is no obligation to exhibit the Program, even if produced; (viii) all decisions by Producers concerning selection of participants are final and not subject to challenge or appeal; and (ix) Producers have no obligation to return any Materials (as defined below) or any other material submitted by you as part of the participant selection process (including without limitation, any video submissions) whether or not you are selected as a participant, and Producers may, but are in no way obligated to, use any such materials in the Program or in any other manner.

(b) By signing below and submitting the Application, you hereby consent to the recording, use and reuse by Producer and NBCU, and each of their respective licensees, successors, assignees, parents, related companies, subsidiaries (whether or not wholly-owned), affiliates, divisions, and the past, present and future officers, directors, agents, representatives, employees, successors and assigns of each of the foregoing, jointly and individually (hereinafter collectively referred to as "Releasees"), of your name, voice, actions, likeness (actual or simulated), sobriquet, appearance, biological and biographical information, and any information contained in, derived from or obtained in connection with the Application (collectively, "Likeness"), as well as any recordings or photographs of you taken during the Participant selection process and any materials, including, without limitation, any photographs or videos, ("Materials") submitted by you (or that you may submit) in connection with the Application, the Participant selection process, and the Program, as edited, altered, or modified by Producer or by any of the other Releasees, in any and all media, whether now known or hereafter devised, throughout the universe, in perpetuity, including, without limitation, in and in connection with the development, production, distribution and/or exploitation of the Program and/or any other production, and the advertising, promotion, publicity, marketing, and merchandising thereof, without any compensation whatsoever. You agree that Releasees may use all or any part of your Likeness and/or the Materials, including in any and all promotions, marketing, advertising or publicity, and may alter or modify such regardless of whether or not you are recognizable. Further, by signing below and submitting the Application, you warrant and represent that everyone appearing in any video submitted by you in connection with the Application (each, a "Video Submission") and anyone who may have shot such Video Submission(s) agrees that such Video Submission(s) may be used, as edited, altered, or modified by Producer or by any of the other Releasees, in any and all media, whether now known or hereafter devised, throughout the universe, in perpetuity, including, without limitation, in and in connection with the development, production, distribution and/or exploitation of the Program and/or any other production, and the advertising, promotion, publicity, marketing, and merchandising thereof, without any compensation whatsoever. You further warrant and represent that you have all rights, licenses, permissions and consents necessary to submit the video and to grant all of the rights that you have granted to Producer herein, and that you have obtained written permission when filming any part of the Video Submission(s) on private property not owned or controlled by you, where such permission is required. You further agree that Releasees exclusively own all right, title, and interest (including, without limitation, all copyrights and extensions and renewals thereof) in and to any such recordings and any other Materials. Without in any way limiting the foregoing, if you perform or include any music (other than music supplied to you by Producer) in connection with your application or the Program, you represent and warrant that you own all rights to such music, and you grant Producer the right to record, reproduce and publicly perform any such music in and in connection with the Program or any other work. Without in any way limiting the waivers and releases set forth herein, you waive any claims to royalties of any kind, whether accruing now or in the future, from Producer and NBCU for the use of any such music, including, without limitation, any applicable copyright, public performance, mechanical and synchronization royalties. You grant the rights hereunder whether or not you are selected to participate as a Participant in the Program. You hereby release Releasees from any and all liability arising out of their recording or use of your Likeness and/or the Materials and any and all claims, actions, damages, liabilities, losses, costs and expenses (including, without limitation, attorneys' fees) in any way arising out of or resulting from the recording or use of your Likeness and/or the Materials. You agree not to make any claim against any of the Releasees as a result of the recording and/or use of your Likeness and/or the Materials (including, without limitation, any claim that such use defames you or invades any right of privacy and/or publicity). You understand that you will not be paid any money for giving Releasees these rights or for signing the Application.

(c) You agree to take any further action, in writing (including, without limitation, execution of affidavits and/or other documents), requested by Producer to effect, perfect or confirm Producer's and NBCU's rights in the Materials and your Likeness, including, without limitation, the rights to use, modify, reproduce, publish, perform, display, distribute, make derivative works of and otherwise commercially and non-commercially exploit the Materials and your Likeness in perpetuity and throughout the universe, in any manner or medium, whether now existing or hereafter developed, without separate compensation to you or any other person or entity.

(d) You understand that the Participant selection process will involve subjective decisions made by certain individuals selected by Producer and/or NBCU in their sole discretion. You understand and agree that all Participant selection and elimination decisions shall be final and binding on you in all respects, and shall not be subject to challenge or appeal.

(e) By signing below and submitting the Application, you hereby release the Releasees and any television station or channel, cable network, or satellite network that airs the Program or the Materials, the other contestants and participants in the Program, the advertisers connected with any program in which the Materials appear (including, without limitation, the Program), each of their respective parent, subsidiary and affiliated companies, all other persons and entities connected with the Program, and the respective officers, directors, agents, representatives, employees, successors, assignees, and licensees of each of the foregoing from any and all claims, actions, damages, liabilities, losses, costs and expenses of any kind (including, without limitation, attorneys' fees) arising out of, resulting from, or by reason of, your participation in or in connection with the Program or the Materials, including, without limitation, your participation in the Participant selection process of the Program, any travel for or in connection with the Program, including, without limitation, any travel to a foreign country, any exploitation of the Program or your appearance on the Program or the Materials, the failure by Producer to select you as a Participant, the cancellation of the Program, or the exercise by Producer of any rights granted by you with respect to the Program or the Materials, on any legal theory whatsoever (including, but not limited to, personal injury, rights of privacy and publicity, false light, and defamation) (the "Released Claims"). The Released Claims specifically include, without limitation, any and all claims, actions, damages, liabilities, losses, costs and expenses (including, without limitation, attorneys' fees) of any kind resulting from the actions of another participant or any other third party at any time.

(f) You hereby authorize Producer to investigate, access and collect information about you, about any of the statements made by you in the Application, any supporting documents and any other document that you submit, have signed or do sign in connection with your application to be selected as a Participant in the Program, or any other written or oral statements you make in connection therewith. Without limiting the foregoing, you irrevocably authorize Producer to secure information about your experiences from your current and former employers, associates, friends, family members, educational institutions, government agencies, credit reporting agencies, any branch of the military and any references you have provided, and you irrevocably authorize such parties to provide information concerning you. You hereby unconditionally and irrevocably release and forever discharge all such parties and persons, as well as the Releasees, from any and all claims, actions, damages, liabilities, losses, costs and expenses (including, without limitation, attorneys' fees) arising out of or in connection with any such investigation. You specifically authorize the investigation of your employment records, medical records, and government records, including, but not limited to, your motor vehicle records, criminal records, civil records, military records, credit and/or consumer report(s). You acknowledge and agree that any such information obtained by Producer pursuant to this paragraph or otherwise may be used for purposes of selecting Participants for the Program, and may be described or otherwise relayed in and in connection with the Program, any another program, and/or any advertising, promotion or publicity therefor.

(g) Whether or not you are selected to be a Participant on the Program, you shall keep in strictest confidence and shall not disclose to any other applicant, Participant or other third party at any time (i.e., prior to, during, or after the taping or exhibition of any episode of the Program) any information or materials of any kind, including without limitation, any information or materials concerning or relating to Producer or to NBCU, the business of Producer or NBCU, any program produced by Producer and/or exhibited by NBCU, including, without limitation, any information concerning or relating to the Program, the Program's applicants, the Participants, the location(s) of the Program, the events contained in the Program, and/or the outcome of any contest in or episode of the Program, that you read, hear or otherwise acquire or learn in connection with or as a result of your applying to be a Participant on the Program or (if you are selected to be a Participant) as the result of your experiences as a Participant on the Program (collectively, the "Information and Materials"). You acknowledge and agree that the Information and Materials are confidential and the exclusive property of Producer and/or NBCU. At no time will you ever, directly or indirectly, divulge in any manner or use or permit others to use any of the Information and Materials.

10. You acknowledge and agree that your obligations with respect to confidentiality set forth herein shall continue in perpetuity or until terminated by Producer by giving you written notice thereof. In no event will you have the right to terminate your confidentiality obligations hereunder. You acknowledge that in the event you breach the confidentiality provisions herein, your breach may, in the sole discretion of Producer and/or NBCU, result in your being disqualified to participate as a Participant in the Program. You further acknowledge that a breach by you of any of the confidentiality provisions herein would cause Producer and NBCU irreparable injury and damage that cannot be reasonably or adequately compensated by damages in an action at law, and, therefore, you hereby expressly agree that Producer and NBCU shall be entitled to injunctive and other equitable relief to prevent and/or remedy any breach or threatened breach of any of the confidentiality provisions herein by you. You also recognize that proof of damages suffered by Producer and NBCU in the event that you breach any of the confidentiality provisions herein will be costly, difficult, and/or inconvenient to ascertain. Accordingly, you agree to pay Producer and NBCU the sum of One Million Dollars ($1,000,000.00) per breach plus disgorgement of any income that you may receive in connection with your breach as liquidated damages in the event you breach any of the confidentiality provisions herein prior to the initial exhibition of the final episode of the Program in which you appear. You agree that One Million Dollars ($1,000,000.00) plus disgorgement of any income that you may receive in connection with such breach is a reasonable estimate of the amount of damages Producer and NBCU are likely to suffer in the event you breach any of the confidentiality provisions herein prior to the initial exhibition of the final episode of the Program in which you appear, considering all of the circumstances existing as of the date of the Application. In addition, you agree to pay Producer and NBCU the sum of One Hundred Thousand Dollars ($100,000.00) per breach plus disgorgement of any income that results from your breach as liquidated damages in the event you breach any of the confidentiality provisions herein after the initial exhibition of the final episode of the Program in which you appear. You agree that One Hundred Thousand Dollars ($100,000.00) plus disgorgement of any income is a reasonable estimate of the amount of damages Producer and NBCU are likely to suffer in the event you breach any of the confidentiality provisions herein after the initial exhibition of the final episode of the Program in which you appear, considering all of the circumstances existing as of the date of the Application.

You agree that Producer may license, assign, and otherwise transfer the Application and all rights granted by you hereunder to any person or entity.

By signing below, you hereby acknowledge that you have read, understand, and agree to be bound by all of the terms and conditions of the foregoing and that all information provided in this Application is true and complete.

By clicking this box you you agree to the terms as set forth in the above release as well as our PRIVACY POLICY and TERMS of USE

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