Lariette Banquet Date Application

*Please fill out and return to me before Friday, March 15th in order to be considered.
Full Name: _____________________________________________
Date of birth: ________/_________/________
Hair color: Brown Blonde Black Other (specify): ________________
Eye color: Brown Blue Hazel Other (specify): ___________________
Relationship status: Single In a relationship with: _____________________
Phone number: (_________) - _________ - ____________
Can you attend the Lariette banquet? Yes No
Will you take pictures with me? Yes No
In the space below, please provide a brief description of how you would like me to
ask you to the Lariette banquet: ____________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

X _____________________________
Signature

______/______/______
Date