APPLICATION FOR THE 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=20 Wrasslin
If You Can Read, Which Magazines Do You Prefer:
___Soap Opera Digest___Rifle and Shotgun ___NWA ___TV Guide ___National
Enquirer ___True Confessions
Which Stinks Worse: ___Hogpen ___Outhouse___Spouse
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___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 Bathed? ___Yup ___Nope
Color of Teeth: ___Yellow ___Brown___Black ___N/A
I hereby swear this is the trooth and sign my "X" on __________________,
2001
