Application to go on the Jerry Springer Show

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?
(_) Booger
(_) 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
(_) Strip Dancer
(_) Hooker
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: ______
Numbers 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

Colour of eyes:
Right_____ left_____

Colour of hair:
(_) Blond
(_) Black
(_) Red
(_) Brown
(_) White
(_) Clairol
Colour 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?