Jerry Springer Show Application

* Last name: ________________

* First name: (Check appropriate box)

* (_) Billy-Bob

* (_) Billy-Joe

* (_) Billy-Ray

* (_) Billy-Sue

* (_) Billy-Mae

* (_) Billy-Jack

* What does everyone call you?

* (_) 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

* 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 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

* Color of eyes:

* Right_____ left_____

* Color of hair:

* (_) Blond

* (_) Black

* (_) Red

* (_) Brown

* (_) White

* (_) Clairol

* Color of teeth:

* (_) Yellow

* (_) Brownish-Yellow

* (_) Brown

* (_) Black

* (_) Not Applicable

* 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?