Prom Date Application

Applicant Information
Full Name:
Last First M.I.

Date:

Address:
Street Address Apartment/Unit #

City

State

ZIP Code

Phone: Dates: May 10th 11th

YES NO

May I pick you up from the above address? Do you enjoy dancing? Have you ever been convicted of a felony?

YES

NO

YES

NO

Where would you like to eat? (Check all that apply)

Red Lobster Olive Garden Outback El Vicino Tortilla Flats Blue Corn Inn of the Anazasi

Other___________________________________ Favorite Color (Color Scheme) ___________________________________________________________________

Personal Suggestions or Comments

Disclaimer and Signature

I hereby certify that my answers and statements are true and complete to the best of my knowledge and ability. If this application leads to a date, I understand that false or misleading information in my application will result in termination of consideration. By signing below I agree that if I am chosen I will follow through, go out to eat, take pictures and dance. PLEASE PRINT AND GIVE TO ME PERSONALY TO BE CONSIDERED!
Signature: 1 Date: