Jerry Springer application
(email 2003-03-05)

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:		 _____
Colour of teeth:

(_) Yellow

(_) Brownish-Yellow

(_) Brown

(_) Black

(_) N/A

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