Please be detailed and honest when answering all questions. Thank you!
Address Line 2
State / Province / Region
Postal / Zip Code
Antigua and Barbuda
Bosnia and Herzegovina
British Indian Ocean Territory
Central African Republic
Democratic Republic of the Congo
Republic of the Congo
Papua New Guinea
Saint Kitts and Nevis
Saint Vincent and the Grenadines
Sao Tome and Principe
Trinidad and Tobago
United Arab Emirates
United States Minor Outlying Islands
Virgin Islands, British
Virgin Islands, U.S.
Occupation(s) of each person in the family.
Please list all the members of your household along with their respective ages.
Do you have pets?
Type of residence (single family home, townhouse, condo, apartment, etc.).
Total number of rooms.
Total number of bedrooms.
Total number of bathrooms.
Square footage of home.
Square footage of lot.
How old is your home?
How long have you lived at this residence?
Do you rent or own?
Describe your family and the dynamics of you living together. Please be detailed.
What is the biggest conflict within your home when it comes to the design & decor? Please describe in detail.
Which rooms do you dislike the most? What are your specific issues with the space(s)? What is the biggest point of contention within the home? Please explain in detail.
Does the conflict of design/decor cause a lot of stress between you and your partner/family/spouse? Explain in detail and give us examples.
What has prevented you from making changes in your home?
What would your dream space be like? Please be detailed.
What is the biggest issue between you and your spouse/significant other right now, not having to do with the design/decor/space? Please explain in detail.
How would a design makeover change your relationship with your spouse/partner/family?
Please attach family photos.
Please attach interior and exterior pictures of your home.
Are you and all of the members in your household legal residents of the United States?
Have you or any of the members in your household ever been convicted of a serious crime of any type?
Have you or any of the members in your household ever been charged with a violent offense?
Have you appeared on any TV shows in the past 5 years?
If yes, please list the name of the show, date and the network:
PLEASE READ AND AGREE TO THE TERMS BELOW BY CHECKING THE APPROPRIATE BOX.
This questionnaire (“Questionnaire”) in no way constitutes an application for employment, as no form of employment is being offered and I am knowingly and voluntarily submitting all of the information in this Questionnaire.
I hereby waive and release City Media Ent., its officers, directors, employees, agents, successors, assigns and/or licensees from any claims, demands or causes of action arising out of or in any way related to this Questionnaire, any information contained herein, and/or the use of any materials submitted by me or taken of me.
I, the undersigned, have voluntarily applied to participate in a television series currently entitled “Interior Therapy with Jeff Lewis” (the “Series”) being produced by Authentic Entertainment, LLC (“Producer”) for possible broadcast by Bravo (the “Network”). In order to be considered as a participant in the Series I have made and will make statements, disclosures and representations (the “Information”) to the Producer and Network regarding myself and my background.
I acknowledge and understand that Producers and Network are detrimentally relying on the Information in order to select possible participants for the Series. As such, I hereby certify, represent and warrant that all Information provided by me or at my direction to Producers and/or Network, including but not limited to any and all Information i) in my application to participate in the Series, ii) in any other document and/or agreement that I have signed or will sign in connection with the Series, and/or iii) any other information (verbal or written) that I have or will otherwise provide to the Producer, Network and/or to anyone acting on their behalf, is true, accurate and wholly complete. Without in any way limiting the foregoing, I certify that I have not or will not withhold or mischaracterize any Information regarding myself or my background. I also agree to immediately inform the Producer and Network if any of the information I provide subsequently becomes inaccurate or incomplete at any time prior to the broadcast of the final episode of the Series.
I hereby acknowledge that if any part of the Information provided to Producer and/or Network is incorrect, inaccurate, misleading and/or incompleteor subsequently becomes such, the Producer and/or the Network may i) immediately remove me from consideration as a participant in the Series if production on the Series has not yet commenced, or ii) immediately remove me as a participant on the Series if production is in progress or has already been completed. In any such instance Producer and/or Network may withhold or cause me to return any prizes, monies and/or other items provided to me in connection with the Series. Furthermore, if I am removed from participation on the Series for any reason referenced under this Certification I acknowledge that any and all construction, design, consulting and/or any other work done to or on my property in connection with the Series will immediately cease and neither Producer nor the Network will be liable for any losses which may result from such ceasation of services.
Additionally, I recognize that proof of damages suffered by the Series producers and the Network in the event that I breach any provision of this certification will be costly, difficult and/or inconvenient. Accordingly, I agree to pay the Series producers and the Network the sum of Two Hundred and Fifty Thousand Dollars ($250,000) per breach plus disgorgement of any money or the value of anything that I may receive in connection with my breach as liquidated damages in the event I breach any provision of this certification.
I shall indemnify and hold harmless the Series producers, the Network, and their respective parent, subsidiary and affiliated companies, and each of their respective officers, directors, agents, representative and employees, from and against any and all claims, actions, damages, liabilities, losses, costs and expenses (including, without limitation, attorney’s fees) that in any way arise out of or result from my breach of any provision of this certification.
If any part of this Certification is found to be invalid, illegal or unenforceable, the validity, legality and enforceability of the remaining provisions will not in any way be affected or impaired.
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