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Application to go on the Jerry Springer Show

> > ============================================


> > Last name: ________________
> > First name: (Check appropriate box)
>> (_) Billy-Bob
>> (_) Billy-Joe
>> (_) Billy-Ray
>> (_) Billy-Sue
>> (_) Billy-Mae
>> (_) Billy-Jack
>>
> > What does everyone call you?
>> (_) Booger
>> (_) Bubba
>> (_) Junior
>> (_) Sissy
>> (_) Other___________________
> > Age: ____ (if unsure, guess) _____ Not sure
> > Shoe Size: ____ Left ____ Right
> > Occupation: (Check appropriate box)
>> (_) Farmer
>> (_) Mechanic
>> (_) Hair Dresser
>> (_) Unemployed
>> (_) Dirty Politician
>> (_) Preacher
>> (_) Strip Dancer
>> (_) Hooker
> > Spouse's Name:_________________________
> > 2nd Spouse's Name:______________________
> > 3rd Spouse's Name:______________________
> > Lover's Name:___________________________
>>
> > Relationship with spouse: (Check appropriate box)
>> (_) Sister
>> (_) Brother
>> (_) Aunt
>> (_) Uncle
>> (_) Cousin
>> (_) Mother
>> (_) Father
>> (_) Son
>> (_) Daughter
>> (_) Pet
>>
> > Number of children living in household: _____
> > Number of children living in shed: ______
> > Numbers that are yours: ______
>>
> > Mother's Name: _______________________(If not sure, leave blank)
> > Father's Name: _______________________(If not sure, leave blank)
>>
> > Education: 1 2 3 4 (Circle highest grade completed)
>>
> > Total number of vehicles you own: ___
> > Number of vehicles that still crank: ___
> > Number of vehicles in front yard: ___
> > Number of vehicles in back yard: ___
> > Number of vehicles on cement blocks: ___
>>
> > Firearms you own and where you keep them:
> > ____ truck
> > ____ bedroom
> > ____ bathroom
> > ____ kitchen
> > ____ shed
>>
> > Model and year of your pickup: 196_
>>
> > Do you have a gun rack?
> > If no, please explain:
>>
> > Newspapers/magazines you subscribe to:
>> (_) The National Enquirer
>> (_) The Globe
>> (_) TV Guide
>> (_) Soap Opera Digest
>> (_) Rifle and Shotgun
>>
> > Number of times you've seen a UFO:_____
> > Number of times in the last 5 years you've seen Elvis:_____
> > Number of times you've seen Elvis in a UFO:_____
>>
> > How often do you bathe:
> > (_) Weekly
> > (_) Monthly
> > (_) Not Applicable
>>
> > Colour of eyes:
> > Right_____ left_____
>>
> > Colour of hair:
> > (_) Blond
> > (_) Black
> > (_) Red
> > (_) Brown
> > (_) White
> > (_) Clairol
> > Colour of teeth:
> > (_) Yellow
> > (_) Brownish-Yellow
> > (_) Brown
> > (_) Black
> > (_) N/A
> > Brand of chewing tobacco you prefer:
> > (_)Red-Man
>>
> > How far is your home from a paved road?
> > (_) 1 mile
> > (_) 2 miles
> > (_) Just a whoop-and-a-holler!
>> (_) road?

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