GUEST
APPLICATION FOR THE JERRY SPRINGER SHOW
Personal Information:
Name___________ Nickname______________ CB
Handle_____
Yore Mama________Yore Daddy (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
of children 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 Mudflaps ___NWO and/or NRA sticker
Weapons Owned: ___Tire Iron ___Pick Handle
___Beer Bottle ___Shotgun
Number of Dogs Owned: ___ Number of
Homemade Tattoo: ___
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 CorrectA: ___"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 Questionaire: 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 and
sign my "X" on _________19__
 
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