JERRY SPRINGER

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 ___ Several of the above

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 many times each grade___________

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___ Number Repossessed___

Truck Equipment: ___Gun Rack ___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 ___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 ___Cigs ___Shotgun Shells ___Whore

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 _________20__