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?
  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

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:

Number 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

Color of eyes:
  Right:
  Left:

Color of hair:
  Blond
  Black
  Red
  Brown
  White
  Clairol

Color 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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