GUEST APPLICATION FOR JERRY SPRINGER SHOW

Personal Information:

Name: __________ Nickname: __________ CB Handle: __________

Yore Mama: __________ Yore Daddy (if known): __________

Spouse's Name: __________ Relationship to spouse: Sister __ Brother __ Mother __ Father __ Pet __ Aunt __ Uncle __

Occupation: Unemployed Mechanic __ Gun Show Dealer __ Skinhead __

Number of Children in Household: __ Number that are yours: __

Circle Highest Level of Education: 1 2 3 4

How Far is Your Mobile Home From a Paved Road? 1 mi. __ 5 mi. __ ? __

Number of Times You Have Survived a Tornado: __

Number of Vehicles Owned: __ Number on Cement Blocks: __

Truck Equipment: Gun Rack __ Pit Bull __ Spit Cup __ Fuzzy Dice __ Rebel Flag __ Naked Woman Mudflaps __ NWO and/or NRA sticker __

Weapons Owned: Tire Iron __ Pick Handle __ Beer Bottle __ Shotgun __

Number of Dogs Owned: __

Number of Homemade Tattoos: __

Which of the Following Appliances are in your Front Yard? Frigerator __ Heatin Stove __ Warsher __ TV __ Freezer __

How Many of the Above Appliances Work? __

Fav-o-rite Recreation: Drinkin __ Cow Chip Throwin __ Possum Huntin __ Crawdad Huntin __ Spittin Backer __ Scratchin __ Watchin Rasslin __

If You Can Read, Which Magazines Do You Prefer? Soap Opera Digest __ NWA __ Rifle and Shotgun __ NWA __ TV Guide __ National Enquirer __ True Confessions __

Which Stinks Worse? Hogpen __ Outhouse __ Spouse __

Can You Spell Your Last Name? Yup __ Nope __

Can You Remember Your Last Name? Yup __ Nope __

Have You Ever Stayed Sober for More Than One Day? Yup __ Nope __

Do You Know Any Words with More Than 4 Letters? Yup __ Nope __

Which is Correct? "I Seed Him" __ "I Seen Him" __

How Many Cartons of Cigarettes Do You Smoke a Day? __

Math Test: How Many Food Stamps Do the Following Cost? Six Pack __ Ciggies __ Shotgun Shells __ Backer __ Prostitute __

Number of Times You've Seen: a UFO __ Elvis __ Elvis in a UFO __

Health Questionnaire: Which of the Following Do You Have? Head Lice __ B.O. __ Crabs __ Runny Nose __ Boils __

Can You Remember the Last Time You Bathed? Yup __ Nope __

Color of Teeth: Yellow __ Brown __ Black __ N/A __

I hereby swear this is the trooth and sign my "X" on __________ 20__