Application Form

Name/Nombre Age/Edad Date of Birth/ Fecha de Nacimiento: (dd/mm/yyyy) DivisionPetite: (3-5)Little Miss: (6-8)Pre-Teen: (9-11)Jr. Miss: (12-14) Hispanic Origin/Nacionalidad Accomplishments / Liste algunos premios o logros especiales Occupation - School / Cual es tu trabajo? / A cual escuela atiendes? Ambition/ Cual es tu ambicion? Phone Number/Numero de Telefono Cell Phone Number/Numero de Telefono Celular Address/Direccion: Address 2/Direccion 2 City/Ciudad State/EstadoConnecticutOther Zipcode/Codigo Postal Email/Correo Electronico: How Did you hear about us?/ Como se Entero Usted de Nosotros? : Check all that apply Referred by a Friend Web Search/Search Engine      Flyer or Other Advertisement      Approached by Queen or Staff Member      Saw Queen at an Event      Contestant Referred Me Other/ Otra: Entry Fee Selection / Seleciona del Pago del Entrada New Delegate: $475; includes city sash & tiara      Returning Delegate Discount: $425 How will you be paying the Entry Fee? / Como tu vas a pagar la entrada del concurso? I will be using a Payment Plan I will send my fee through the mail      I will pay my fee online via PayPal Headshot Photo / Foto I will email to ctbellezalatina@yahoo.com I will send my photo in the mail Agreement By submitting the entry form and fee(s) to CT Belleza Latina, delegate agrees to abide by all policies, rules and regulations set forth by the CT Belleza Latina Pageants. Participation in the CT Belleza Latina Pageant also indicates acceptance and agreement to abide by all policies, rules and regulations set forth by the CT Belleza Latina Pageant. Delegate attests that all information submitted to the CT Belleza Latina Pageant is true and accurate. Falsification of information and failure to comply with the policies of CT Belleza Latina may result in immediate disqualification and/or forfeiture of prizes won without benefit of refund in full or in part at the sole discretion of the CT Belleza Latina State Pageant. By clicking "I Agree - Submit my Entry" below, I am attaching my electronic signature to and agreeing to the AGREEMENT above. I understand that if I do not agree to the agreement, I should not continue