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
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 Tattoo: ___
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
Hunti
___Spittin Backy
___Scratchin ___Watchin 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
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 A: ___"I Seed Him" or B:___"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 Questionnaire: 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 _________19__