Application For The Jerry Springer Show

APPLICATION FOR THE JERRY SPRINGER SHOW:

Personal Information:
Name___________ Nickname______________ CB Handle_____

Yore Muma________Yore Diddy (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 of children 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 Survived a Tornader: ___

Number of Vehicles Owned___ Number on Cement Blocks____

Truck Equipment: ___Gun Rack ___PitBull ___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 ___ Rifle and Shotgun ___NWO ___TV Guide ___National Enquirer___True Confessions ___Soldier of Fortune __Mini Trucker

Which Stinks Warse?: ___Hogpen___Outhouse ___Spouse

Can You Spell Your Last Name?:___Yup___Nope

Can You Remember Your Last Name?:___Yup ___Nope

Ever Stayed Sober for More'n a Day?:___Yup ___Nope

Do You Know Any Words with More'n 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 ___Prostitute

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. ___Crabs___Runny Nose ___Boils

Can You Remember the Last Time You Done Bathed?
___Yup ___Nope

Color of Teeth: ___Yellow ___Brown___Black ___N/A

I hereby swear this is the trooth and sign my "X" on _________19___