PRINT OUT FORM & FILL IN - MAILING WITH PHOTO TO ADDRESS BELOW
EKLECTRA Presents Records. Inc.
"PIPER'S PICS" TV SHOW
Simply Platinum Model Registration
CONTACT NAME: _______________________________
PHONE NO.____________________________________________
ADDRESS:_______________________________________________________________________________
E:Mail*______________________________________
contestant's NAME:________________________________________________________________________________
TALENTS:_________________________________________________________________ AGE________
EDUCATION;____________________________________________________________________________
TITLES HELD:__________________________________________________________________________________
CURRENT TITLE__________________________________________________________________________________
EKLECTRA Presents Records, Inc.
P. O. Box 609040
Orlando, FL 32860-9040
321-947-6447 321-948-6282 http:/Eklectra.us eklectrarecords@aol.com
