Name:_________________________
Stage Name:____________________
Agent:_________________________
Attorney:_______________________
Sex: ___Male ___Female ___Formerly Male ___Formerly Female___Both
If Female, indicate breast implant size:____________________________
Will the size of your implants hinder your ability to safely operate a motor vehicle?
___No ___Yes
Please list brand of cell phone: __________________________________
If you don't own a cell phone, please explain: ______________________
Please check hair color:
Females: [ ] Blonde [ ] Platinum Blonde
Teenagers: [ ] Purple [ ] Blue [ ] Skinhead
Please check activities you perform while driving: (Check all that apply)
[ ] Eating
[ ] Applying makeup
[ ] Talking on the phone
[ ] Slapping kids in the back seat
[ ] Applying cellulite treatment to thighs
[ ] Tanning
[X] Snorting cocaine (already checked for your convenience)
[ ] Watching TV
[ ] Reading Variety
[ ] Surfing the net via laptop
Please indicate how many times
a) You expect to shoot at other drivers________
b) You expect to be shot at while driving ______
If you are the victim of a car jacking, you should immediately
a) Call the police to report the crime
b) Call Channel 4 News to report the crime, then watch you car on the news in a high speed chase
c) Call your attorney and discuss lawsuit against cellular phone company for 911 call not going through
d) Call your therapist
e) None of the above (South Central residents only)
In the event of an earthquake, you should
a) Stop your car
b) Keep driving and hope for the best
c) Immediately use your cell phone to call everyone you know
d) Pull out your video camera and obtain footage for Channel 4
In the event of rain, you should
a) Never drive over 5 MPH
b) Drive twice as fast as usual
c) You're not sure what "rain" is
Are you presently taking any of the following medications?
[ ] Prozac [ ] Zovirax [ ] Lithium [ ] Zanax [ ] Valium [ ] Zoloft
If none, please explain________________________________
Please indicate number of therapy sessions per week _______
Length of daily commute
[ ] 1 hour [ ] 2 hours [ ] 3 hours [ ] 4 hours or more
If stopped by police, you should
[ ] Pull over and have your driver's license and insurance form ready
[ ] Try to outrun them and the news helicopters
[ ] Have your video camera ready, provoke an attack, and thus ensure yourself a hefty lawsuit
