Be On Jerry Springer!

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
(_) Exotic Dancer

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 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:

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:_____

Color of teeth:
(_) Yellow
(_) Brownish-Yellow
(_) Brown
(_) Black
(_) N/A