Vous êtes sur la page 1sur 5

Africa Heritage House

325 Rivonia Boulavard, Rivonia 2128, Sandton, Johannesburg, South Africa, Mobile: +260 960 502 678
| Email: zuriinfo@zoho.com/ info@zuriafrica.co.za | Web: www.zuriafrica.co.za

Zuri Africa 2018/2019


Entry Form
Country: __________________________________________

Full Name: (family name)______________________________

(First name)__________________________________________

I prefer to be called :__________________________________

Address:____________________________________________ Place Photo

____________________________________________________

Telephone No.(Home): (Area code & No.) __________________

Telephone No. (College): (Area code & No)__________________

Mobile No: ___________________________________________

E-Mail Address:________________________________________

Age: ______ Date of Birth: _________________ Place of Birth: __________________________________

Citizernship:______________________________ Passport No: __________________________________

Native Language: __________________________ Occupation (if any):___________________________


nd
2 Foreign Language:_____________________________

University: Name:______________________________________________________

Address:_____________________________________________________

Major:_________________________________ Minor (if any):____________ What Year:_____________

Ambition:_____________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

DISCLAIMER: This message is intended only for the use of the persons ("Intended Recipient") to whom it is addressed. It may contain
information, which is privileged and confidential. Accordingly any dissemination, distribution, copying or other use of this message or any of its
content by person other than the intended Recipient may constitute a breach of civil or criminal law and is strictly prohibited. If you are not the
Intended Recipient, please contact the sender as soon as possible. Commercial-in-Confidence / Without Prejudice
1
Hobbies:______________________________________________________________________________

Special Talent:__________________________________________________________________________________

If working, please state employers name &


address:_______________________________________________________________________________________
____________________________________________________________________________________________

Vital Statistics
Hair color: ________________ Eyes color:_______________ Height:_____________ Weight (Kg):__________

Bust (Inch): _____________________ Waist (Inch): __________________ Hips (Inch):____________________

Shoe size:__________________________________________________________________________________

Dress size: _________________________________________________________________________________

Other Details
Have you ever been chosen to be a leader? _____________ When? __________________________

Have you ever won any award?:________________________________________________________

If so, kindly name:___________________________________________________________________

List your favorites in each of the followings:-

Sports:___________________________ Sport personality:__________________________________

Movie:____________________________ Actors/Actress:___________________________________

Song:______________________________ Singer:_________________________________________

Food:______________________________ Food type:______________________________________

Favourate person you would like to meet:________________________________________________

Blood type of participant:______________________________________________________________

Do you have any illness?:_______________________________________________________________

If so, please state in details:_____________________________________________________________

Name of person to contact in emergency:___________________________ Relationship:____________________

Address:______________________________________________________________________________________
_________________________________________________________ Tel:_________________________________

DISCLAIMER: This message is intended only for the use of the persons ("Intended Recipient") to whom it is addressed. It may contain
information, which is privileged and confidential. Accordingly any dissemination, distribution, copying or other use of this message or any of its
content by person other than the intended Recipient may constitute a breach of civil or criminal law and is strictly prohibited. If you are not the
Intended Recipient, please contact the sender as soon as possible. Commercial-in-Confidence / Without Prejudice
2
Fathers name:_______________________________________ Occupation:_______________________________

Mothers name:______________________________________ Occupation: _______________________________

Address:______________________________________________________________________________________
__________________________________________________________ Tel:________________________________

Is there anyone travelling with you to Zambia, if yes, please list name & relationship

Name:_____________________________________________ Relationship:_______________________________

“ I declare that the above answers are true to the best of my knowledge and that I will abide by the regulations
governing Zuri Africa Program. I understand that I will be disqualified if any information I have given is found to be
incorrect”.

Participant’s Name & Signature


Name:_______________________________ Signature:_________________________ Date:__________________

National Organising Committee’s Authentication


We declare that the above information given is true and correct to the best of our knowledge.

Executive title:_____________________________ Signature:____________________ Date:_________________

Address:______________________________________________________________________________________

Tel No.: (Area Code & No)_________________________ Fax No.:(Area Code & No.)_________________________

E-mail(s):_____________________________________________________________________________________

DISCLAIMER: This message is intended only for the use of the persons ("Intended Recipient") to whom it is addressed. It may contain
information, which is privileged and confidential. Accordingly any dissemination, distribution, copying or other use of this message or any of its
content by person other than the intended Recipient may constitute a breach of civil or criminal law and is strictly prohibited. If you are not the
Intended Recipient, please contact the sender as soon as possible. Commercial-in-Confidence / Without Prejudice
3
Contestant’s Measurement

Name:

All measurements to be accurate as possible

Height:_______________________ (inches)___________________(cm)

Weight:_______________________(LBS)_____________________(kg)

Dress Size: USA__________________ Europe___________________

Shoe Size: USA__________________ Europe____________________

Measurement Inches Centimeter


1 Bust/Chest
2 Waist
3 Hips
4 Things
5 Neck to waist
6 Shoulder to wrist
7 Neck
8 Shoulder
9 Waist to heel
10 Waist to crotch

Participant’s Declaration
Participant’s Name:
(Name)___________________________________________________________________________
Participants Address:________________________________________________________________

Being the above mentioned contestant, I hereby declare and agree that I have read and understood all
the forgoing. I hereby agree to participate in the forthcoming Zuri Africa Queen program in accordance
with the terms and conditions set by the Zuri Africa cultural and leadership program and abide by the
decision of the program judges which is deemed final.

DISCLAIMER: This message is intended only for the use of the persons ("Intended Recipient") to whom it is addressed. It may contain
information, which is privileged and confidential. Accordingly any dissemination, distribution, copying or other use of this message or any of its
content by person other than the intended Recipient may constitute a breach of civil or criminal law and is strictly prohibited. If you are not the
Intended Recipient, please contact the sender as soon as possible. Commercial-in-Confidence / Without Prejudice
4
Participants Signature:________________________________________ Date:____________________

Witnessed by: (National Organising Committee)______________________________________________

(Executive Title & Signature)_____________________________________ Date:____________________

National Organising Committee Declaration


We hereby certify that Miss _______________________________________ is duly selected and fit to
participate in Zuri Africa program and that we have no objections to her participation.

Country: _________________________________________

Executive Title: ___________________________________

Signature:_______________________ Date:____________

*Entry forms without photographs will not be processed


*Every participant should also submit a video clip and 4 For office use: ___________________________________
photographs (1 torso & 3 full length) Application Received:______________________________
*Please make sure that all participants have valid passport Remarks:_________________________________________
________________________________________________
________________________________________________
________________________________________________
*Warning: Human trafficking, drug trafficking or ________________________________________________
drug use is an offence & we will not be liable. ________________________________________________
________________________________________________
_________________________________________________

DISCLAIMER: This message is intended only for the use of the persons ("Intended Recipient") to whom it is addressed. It may contain
information, which is privileged and confidential. Accordingly any dissemination, distribution, copying or other use of this message or any of its
content by person other than the intended Recipient may constitute a breach of civil or criminal law and is strictly prohibited. If you are not the
Intended Recipient, please contact the sender as soon as possible. Commercial-in-Confidence / Without Prejudice
5

Vous aimerez peut-être aussi