GUEST APPLICATION FOR THE
JERRY SPRINGER SHOW
Personal Information:
Name___________ Nickname______________
CB Handle___________
Yore Mama Name______________
Yore Daddy Name(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 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 ___Rebel
Flag
___Naked Woman Mud flaps ___NRA
sticker
Weapons Owned: ___Tire Iron ___Pick Handle
___Beer Bottle ___Shotgun
Number of Dogs Owned: ___
Number of Homemade Tattoos: ___
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 Correct?:
___"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 Questionnaire: Which of the
Following Do You Have?
___Head Lice ___B.O. ___Crabs ___Runny Nose ___Boils
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 sign my "X" on
______________200__
