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GUEST APPLICATION FOR THE 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 of children 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 ___ 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 Huntin ___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 CorrectA: ___"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 ___Ciggies ___Shotgun Shells ___Backy ___Prostitute Number of Times You've Seen: ___a UFO ___ Elvis ___Elvis in a UFO Health Questionaire: Which of the Following
Do You Have? 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 and sign my "X" on _________19__
 
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