ENTRY BLANK/FACT SHEET

51st Annual

2010 MISS MACOMB SCHOLARSHIP PAGEANT

“A Macomb Tradition for 51 Years”

(An Official preliminary to the Miss Illinois and Miss America Pageants)

PERSONAL FACTS

Student ID or

NAME___________________________________________SS#____________________________

e-mail____________________________________________Cell Phone_______________ _____

School Address_____________________________________ School Phone__________________

Hometown Address ______________________City_______________State_______Zip_________

Home Phone_ ________________Age ________Birth Date _________ Birth Place _____________

Year in College (Freshman, etc.) _____________________________________________________

Are you now in High School? _________________________________________________________

iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii

FAMILY

Father___________________________________________________________________________

Mother__________________________________________________________________________

Parents Address – Street _______________________City____________________ Zip __________

Parent’s Phone Number _____________________________________________________________

Brothers & Sisters (names & ages) ____________________________________________________

iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii

TALENT

What will your talent presentation be? __________________________________________________

What training have you had in music, dancing, theatre, etc.?__ ______________________________

iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii

iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii

PLATFORM

What is the title of your Platform? _____________________________________________________

SERVICE

What kind of service, honors and involvement have you had in your community? _______________

iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii

EDUCATION

High School _____________________________________________Year Graduated ____________

High School Honors & Activities ______________________________________________________

College or University _______________________________________________________________

Major _______________________________________Minor________________________________

Why did you select this College or University? ___________________________________________

College Activities, Honors & Awards ___________________________________________________

iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii

OTHER FACTS

Hobbies _________________________________________________________________________

Sports in which you participate ________________________________________________________

Ambition for the future ______________________________________________________________

Interesting facts about yourself _______________________________________________________

iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii

Do you now hold a “pageant title” of any kind? Yes __________________ No __________________

If “Yes”, what title do you now hold? ___________________________________________________

What other titles have you held in the past ______________________________________________

I hereby acknowledge that I am complying with all the rules and regulations of this pageant and the data and facts contained herein on this Entry Blank/Application are true and accurate.

Signature_________________________________

The following attachments are required , if applicable. Check space if included.

(____) Birth Certificate

(____) Proof of Residence (Driver’s License)

(____) Copy of College Transcript (of last semester)

(____) Copy of College Registration for current classes

(____) Copy of College Degree, if applicable

Pageant Date: Sunday, March 7, 2010

E-mail, and then Mail or Deliver signed Entry Blank to:

Bob and Nancy Foote

726 Auburn Drive

Macomb, Illinois 61455

e-mail: 2footes@macomb.com

Phone: (309) 833-2898

PLEASE NOTE:

All information on the Application/Entry Blank, should be typed on the three previous pages. Do not construct your own Entry Blank.

Application can be e-mailed but it is required that a hard copy, properly signed, with attachments, be mailed or presented to the Footes.

You will be notified when the Application/Entry Blank has been received.