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Application to go on the Jerry Springer Show
If you cannot read or write have the nearest non-related 8 year old help you.




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)

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: K 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 an alien has given you an anal probe:_____

Number of times in the last 5 years you’ve seen Elvis:_____

Number of times you’ve seen Elvis in a UFO:_____

Number of times Elvis has given you an anal probe:_____

How often do you bathe:
.....(_) Weekly
.....(_) Monthly
.....(_) Not Applicable

Color of eyes: Right_____ left_____

Color of hair:
.....(_) Blond
.....(_) Black
.....(_) Red
.....(_) Brown
.....(_) White
.....(_) Clairol
.....(_) Skin head

How many teeth do you have left? _____

Color of teeth:
.....(_) Yellow
.....(_) Brownish-Yellow
.....(_) Brown
.....(_) Black
.....(_) N/A

Brand of chewing tobacco you prefer:
.....(_)Red-Man

How far is your home/trailer from a paved road?
.....(_) 1 mile
.....(_) 2 miles
.....(_) Just a whoop-and-a-holler!
.....(_) road?
 
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