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FIRST NAME:

LAST NAME:

LEGAL NAME AS IT APPEARS ON STATE - ISSUED I.D.: :

AGE:

CURRENT OCCUPATION:

CELL PHONE:

ALT. PHONE:

EMAIL ADDRESS:

CURRENT STREET ADDRESS:

CITY:

STATE:

ZIPCODE:

NEAREST AIRPORT:

I grew up in (List all Cities and States):

MYSPACE/FACEBOOK/WEBSITE ADDRESS: :

EMERGENCY CONTACT NAME:

EMERGENCY CONTACT PHONE NUMBER:

I AM A LAWFUL U.S. RESIDENT:

yes

no

DO YOU HAVE ANY CHILDREN? If yes, list all names and ages:

HAVE YOU APPLIED FOR ANY OTHER TV SHOW (REALITY/GAME SHOW OR OTHERWISE) IN THE PAST 6 MONTHS? Please list project title and the dates that you have applied:

PARTNER CONTACT and BACKGROUND INFORMATION

FIRST NAME:

LAST NAME:

LEGAL NAME AS IT APPEARS ON STATE - ISSUED I.D.: :

AGE:

CURRENT OCCUPATION:

CELL PHONE:

ALT. PHONE:

EMAIL ADDRESS:

CURRENT STREET ADDRESS:

CITY:

STATE:

ZIPCODE:

NEAREST AIRPORT:

I grew up in (List all Cities and States):

MYSPACE/FACEBOOK/WEBSITE ADDRESS: :

EMERGENCY CONTACT NAME:

EMERGENCY CONTACT PHONE NUMBER:

I AM A LAWFUL U.S. RESIDENT:

yes

no

DO YOU HAVE ANY CHILDREN? If yes, list all names and ages:

HAVE YOU APPLIED FOR ANY OTHER TV SHOW (REALITY/GAME SHOW OR OTHERWISE) IN THE PAST 6 MONTHS? Please list project title and the dates that you have applied:

YOUR FITNESS INFORMATION

HEIGHT:

CURRENT WEIGHT:

GOAL WEIGHT:

LEAST YOU WEIGHED IN LAST 5 YEARS: :

MOST YOU WEIGHED IN LAST 5 YEARS:

GIRLS: DRESS SIZE or GUYS: WAIST SIZE:

Do you have any medical conditions that could be harmed by physical activity or impair your ability to exercise? :

Do you have a medical condition that causes you to be overweight? :

When in your life do you think you looked and felt you best? :

Who, or what do you think is keeping you from achieving your ideal body? :

Have you had success in the past with weight loss, dieting, and personal fitness? If so, what worked for you, and what didn’t? :

What is the most amount of weight you’ve lost on a previous diet? :

Have you ever undergone a medical procedure to lose weight (Liposuction, Lap Band, Gastric Bypass)?:

If yes, please identify the procedure

What is your current level of fitness or endurance? Check any of the activities listed below in which you currently participate:

If you checked off "cleaning your house" above, how many bedrooms is it?:

Please check ONE of the following:

I exercise/work out several times a week

I exercise/work out on the weekends

I exercise/work out a couple of times a month

I hardly ever work out

I have never exercised/worked out before

I used to be very active

PARTNER FITNESS INFORMATION

HEIGHT:

CURRENT WEIGHT:

GOAL WEIGHT:

LEAST YOU WEIGHED IN LAST 5 YEARS: :

MOST YOU WEIGHED IN LAST 5 YEARS:

GIRLS: DRESS SIZE or GUYS: WAIST SIZE:

Do you have any medical conditions that could be harmed by physical activity or impair your ability to exercise? :

Do you have a medical condition that causes you to be overweight? :

When in your life do you think you looked and felt you best? :

Who, or what do you think is keeping you from achieving your ideal body? :

Have you had success in the past with weight loss, dieting, and personal fitness? If so, what worked for you, and what didn’t? :

What is the most amount of weight you’ve lost on a previous diet? :

Have you ever undergone a medical procedure to lose weight (Liposuction, Lap Band, Gastric Bypass)?:

If yes, please identify the procedure

What is your current level of fitness or endurance? Check any of the activities listed below in which you currently participate:

If you checked off "cleaning your house" above, how many bedrooms is it?:

Please check ONE of the following:

I exercise/work out several times a week

I exercise/work out on the weekends

I exercise/work out a couple of times a month

I hardly ever work out

I have never exercised/worked out before

I used to be very active

RELATIONSHIP INFORMATION

How long have you been with your partner? :

How did you two meet? :

Do you live together? :

Do you have children together? (if yes, how many and ages) :

In your own words, describe your current relationship and how happy/unhappy you are:

What are your partner’s worst qualities? :

What are your partner’s best qualities? :

What issues usually cause arguments? :

Who is usually the instigator in the relationship? How so? :

Who is usually the problem solver in the relationship? How so? :

What are the biggest issues in your relationship that you would like to work on as a team? :

How much of your relationship problems are caused by the weight struggles? :

What changes do you hope your partner will undergo while on the show? :

How important is losing weight to you? Would you say it is more important or less important than to your partner? :

How does having an overweight partner affect your eating habits and lifestyle? :

Do you and your partner have an active sex life together? Explain how often you feel romantic and sexually turned on by your partner:

Would you find your partner more attractive if he/she lost weight? :

Has your partner ever broken your heart or hurt your feelings? What happened? :

If you could sum up your relationship in ANY 3 words, what would they be? :

If you achieved your ideal body type and weight goal, would you need your partner to do the same? :

Have you appeared on a television show (including but not limited to reality, scripted, commercial, film) or any other media including print (magazines, online publications etc) in the past 3 years?:

If yes, please list PROJECT TITLE, AIR or RELEASE DATE, and how many episodes/issues etc. you appeared in.

I acknowledge that everything stated in this application is true. I understand that any falsely submitted answers can and will be grounds for removal from the casting process and from my subsequent participation in the pilot or final series. I further acknowledge and accept that this application form and any other materials (including, but not limited to, photographs, videotapes, etc.) that I have submitted or will submit to 495 Productions, Inc. will become the property of 495 Productions, Inc. and will not be returned. By signing below, I hereby grant 495 Productions, Inc. the right to use any biographical information contained in this application, my home video, taped interview and any other materials submitted by me in any manner and for any purpose in all media now known or hereafter devised throughout the world in perpetuity without any compensation to me. Such rights shall include, without limitation, the right to record, use, publicize, distribute and otherwise exploit my home video tape or taped interview, voice, actions, likeness, biographical information and appearance and any other material submitted by me in any manner and for any purpose (including, without limitation, in connection with 495 Productions, Inc.).

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