>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: ___1mi. __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:___Friggerator
>___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 Backy ___Scratchin___Watchin Wrasslin
>
>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" or ___"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 ___Backy
>
>Number of Times You've Seen: ___a UFO ___ Elvis___Elvis in a UFO
>
>Health Questionaire: Which of the Following Do You Have?
>___Head Lice ___B.O. ___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 _________19__
Scott Paceley * spaceley@uiuc.edu * 217-333-8759 * Champaign, Illinois
graphic design, photography, photo-illustration
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