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I,  agree to complete and submit this story submission form (the "Form") for the purpose of being considered to become a participant in the television show currently entitled "I Survived…" (the "Program"), produced by NHNZ Limited ("Producer"). I am making the representations, disclosures, and agreements described below in this Form so that Producer will continue to consider me to become a participant in the Series. If any disclosure or representation is false, misleading or incomplete, or if I breach any agreement made in connection with the Series, Producer may remove me from further consideration as a participant.

I agree that I have not made, nor will I ever make any false or misleading statements regarding the Program, my participation in the Program, or the person that I am submitting for appearance in the Program ("Subject"). I agree that I have not, nor will I engage in any deceptive or dishonest act with respect to the Program, including but not limited to revealing any confidential knowledge I have with respect to the Program.

Please type in your NAME here which signifies that you are agreeing to the above terms of the Story Submission Form: 

 Please check this box which signifies that you are agreeing to the above terms of the Story Submission Form.

Confirmation Phone (same as phone above):     

Date:      (mm/dd/yyyy)

Person who is the subject of the story: 

Additional Materials Supplied: 
(Do not exceed 60 characters)
If none, please type in NA