FORM (THE “NOMINATION FORM”) INCLUDING THE TERMS AND CONDITIONS REFERRED TO, VERY CAREFULLY BEFORE COMPLETING AND SIGNING. PLEASE FILL OUT ONE APPLICATION FORM FOR EACH PERSON OR GROUP OF PEOPLE YOU WISH TO NOMINATE (THE “NOMINEE(S)”) ****YOU ARE REQUIRED TO KEEP THIS NOMINATION A SECRET AT ALL TIMES**** ELIGIBILITY REQUIREMENTS: In order to participate in the Programme neither you nor the Nominee(s) can be: a. currently employed by ITV Studios Limited (“we”, “us”, “our”), the ITV group of companies or the holders of the OFCOM Channel 3 licences (which at the time of writing and for the purposes of this Nomination Form consist of ITV Broadcasting Limited, Channel Television Limited, STV North Limited, STV Central Limited and UTV Limited and any successor or replacement licensees) (with the foregoing licence holders collectively referred to as the "Broadcaster") and have not been previously employed by us, any of the ITV group of companies or the Broadcaster; or b. a live-in partner or immediate relative (i.e. mother, father, son, daughter, brother or sister) of an employee of ours or the Broadcaster or any of the ITV group of companies. (the foregoing shall be referred to as the “Eligibility Requirements”) YOUR INFORMATION (We need your details even though you are nominating someone else. If you are under 18, please arrange for a parent/legal guardian to complete this form on your behalf) Full Name:

Date of Birth:


Home Tel:


Work Tel:

E-mail (NOTE: this must be a private e-mail address for contact with you only)


When is the best time to contact you?

How did you hear about the Programme?

worst and funniest character traits) How do you think they would react to being surprised on live national television? FURTHER QUESTIONS ABOUT THE NOMINEE(S) ABOUT THEIR PERSONALITY Tell us about their personality. which you feel the Nominee(s) would not agree to you providing information to us on.DETAILS ABOUT THE NOMINEE(S) You will need to complete details about the Nominee(s) below. If it is a group of people that you are nominating. on holiday) Residency of the Nominee(s): How do you know your Nominee(s)? Describe your Nominee (personality / best. and tell us some stories about them. Number of people being nominated: Full Name of Nominee(s): Date of Birth of Nominee(s): Address of Nominee(s): Telephone number of the Nominee(s): What is the URL link to their Facebook / Twitter pages? Occupation of the Nominee(s) Do they have any unavailable dates between January and April 2013? (e.g. then please state how many people in total and the details. Note: With regard to any information we request of you in this Nomination Form which relates to the Nominee(s) please only provide information you feel the Nominee(s) would agree to you to passing on to us. If the Nominee(s) is/are under 18 years old please include the name and phone number of the Nominee(s) parent/legal guardian. please specify as such next to the relevant question. Try answering the questions below. If you do feel that there is any question. Fill in your answers below .

at home. out shopping… Feel free to tell us any other funny stories about this person – the more we know the better! ABOUT THEIR HOBBIES AND INTERESTS Tell us about what this person likes doing in their spare time. down the pub.What makes them special and why are you nominating them for a surprise? What is the naughtiest thing they have ever done? Have they ever told any big lies to cover to their friends. family. partner or neighbours? Are they a practical joker? What sort of jokes do they play? What is the most outrageous thing they have done on a holiday / at work / on a night out? Do they have any funny dating/romance stories? What is the funniest story you can tell us about them? This can be anything that happened at work. on holiday.g Robbie . What are their hobbies and interests? Fill in your answers below Do they have any special talents? Who are their favourite celebrities/ TV shows and tell us about any embarrassing celebrity crushes? Are they a ‘superfan’ of anyone e.

itv. you hereby agree to be bound by the Ant and Dec’s Saturday Night Takeaway Series 10 Nomination Terms and Conditions detailed at [http://www. playing in a big sporting event?) PHOTOS: Please attach a photo of yourself and the Nominee(s) to this Nomination Form. Fill in your answers below WORK What hours do they work? Please give days and specific working hours where possible.Williams Do they have any weird or embarrassing habits? WORK & SPARE TIME Please tell us some information about their working life and any special occasions they have coming up. If you are happy for us to retain the information you have provided in this Nomination Form and which you may provide to us elsewhere during the selection process and/or during production of the Programme for the above purposes. having a party. we would like to keep all the information you have provided in this Nomination Form to be considered for other features and items within the Programme (the “ Other Item(s)”) (Please] (the “Terms and Conditions”) WOULD YOU LIKE YOUR NOMINATION TO BE CONSIDERED FOR OTHER FEATURES IN THE PROGRAMME? Should you consent and reasonably believe that the Nominee(s) would consent. please indicate this by ticking the relevant box below. Please note that your refusal to grant us such permission will in no way influence our selection process with regard to this nomination. TERMS AND CONDITIONS: By submitting this Nomination Form. you may be contacted by a member of the Programme production team working on the Other Item(s)). Use of all the information you have provided in this Please only tick the box below if you would like and believe that the Nominee(s) would consent to all the information you have provided in this Nomination Form and any information which you may provide to us elsewhere during the selection process and/or during production of the Programme (including any Personal . Do they have to work on Saturday nights? What does their job involve? SPECIAL OCCASIONS Do they have any special events coming up in Feb/March/April 2013? (Are they or is someone they know getting married. that if you agree to this.

understood and agree to the Terms and Conditions. SE1 9LT (Note: Please be aware that if you do send photos by post.) The closing date for nominations is Friday 5 April 2013 (the “ Closing Date”). London. Signature (if emailing this form type in your name): Print Name: Date: Signature of parent / legal guardian (if you are under 18): Print Name: Date: . The London Television or by post to: Ant and Dec’s Saturday Night Takeaway. your nomination must reach us by the Closing Date. that if you are contacted by us to be considered for any Other Item(s) you will be asked to update us of any changes to the information you have provided in this Nomination Form at such time we make contact with you and if deemed appropriate you may be asked to complete a new form if we so request.Nomination Form for the Other Item(s) Data and Sensitive Personal Data (as defined in the Terms and Conditions) to be retained by us so you can be considered for the Other Item(s) . Upper Ground. If you are returning your nomination by post. Please note. WHAT TO DO NEXT: Please make sure that you have completed ALL SECTIONS of this Nomination Form and email it back to us attached with recent photographs of both yourself and your Nominee(s) by email to: takeaway@itv. and you have read. By returning this completed Nomination Form you confirm that: (i) (ii) you have answered all the questions in this Nomination Form honestly and truthfully. we will be unable to return them.