application

If you meet the eligibility requirements and there is not a state pageant held in your state, you may apply online as an At-Large Delegate. To apply, complete and submit the online application, upload a recent photo and pay your $50.00 non-refundable application fee.

ALL FIELDS WITH * MUST BE FILLED OUT OR YOUR REQUEST WILL NOT BE PROCESSED.

Miss Black USA Online Application

Name:

Date of Birth:

Street Address:

City:

State:

Zip Code:

Home Phone:

Message Phone:

Email:

I wish to apply to represent:

I certify that I:

in this state.

Pageants previously entered (Titles, if any):

School or University:

Employer:

Education level and all degrees received:

GPA:

Parent or Guardian if under 18:

Are you currently under any contracts?

If you selected "Yes" above, please explain:

What is your platform?

What is your talent/talents?

How did you hear about this pageant?

I authorize the verification of the information provided on this form. I certify that I am a single (unmarried) female, was born female gender, between the ages of 17 and 27, and I am eligible to compete for the title of Miss Black USA Pageant. You must be 17 and no older than 27 by the date of competition, August 5, 2010.

Note: Your online application will not be processed without payment of the $50 non-refundable application fee.

Print Name:

Date:

Print Signature: