Email *
First/Last Name *
Phone *
City *
Age *
State *
PHOTO of you & your EX (no larger than 1MB) *
Current relationship status? *
How long did you date your EX & when did you breakup?
Have you been on a REALITY TV show before? *
MAKE SHORT VIDEO & SEND YOUTUBE LINK ONLY (tell us about the EX, the relationship details & what caused the breakup ..and why you want a 2nd chance)