Name:______________ Stage name: ________________
Agent:______________ Attorney:__________________
Sex:___male ___female ___formerly male ___formerly female____both
If female, indicate breast implant size: ____
Will the size of your implants hinder your ability to safely operate a motor vehicle in any way?
Yes___ No ___
Please list:
Brand of cell phone: ________.
(If you don't own a cell phone, please explain.)
Please check haircolor:
Females: [ ] Blonde [ ] Platinum Blonde
Teenagers: [ ] Purple [ ] Blue [ ] Skinhead
Please check activities you perform while driving:
(Check all that apply)
[ ] Eating
[ ] Applying make-up
[ ] Talking on the phone
[ ] Slapping kids in the backseat
[ ] Having sex
[ ] Applying cellulite treatment to thighs
[ ] Tanning
[X] Snorting cocaine (already checked for ease of application)
[ ] Watching TV
[ ] Reading Variety
[ ] Surfing the net via laptop
Please indicate how many times:
a) you expect to shoot at other drivers ________
b) how many times you expect to be shot at while driving ________
TEST
If you are the victim of a carjacking, you should immediately:
a) Call the police to report the crime;
b) Call Channel 4 News to report the crime, then watch your car on the news on a high-speed chase
c) Call your attorney and discuss lawsuit against cellular phone company for 911 call not going through
d) Call your therapist
e) None of the above (South Central residents only).
In the event of an earthquake, should you:
a) Stop your car
b) Keep driving and hope for the best
c) Immediately use your cell phone to call all loved ones
d) Pull out your video camera and obtain footage for Channel 4
In the instance of rain, you should:
a) Never drive over 5 MPH
b) Drive twice as fast as usual
c) You're not sure what "rain" is
Please indicate number of therapy sessions per week: ____.
Are you presently taking any of the following medications?
a) Prozac
b) Zovirax
c) Lithium
d) Zanax
e) Valium
If none, please explain: __________________.
Length of daily commute:
a) 1 hour
b) 2 hours
c) 3 hours
d) 4 hours or more
When stopped by police, should you:
a) Pull over and have your driver's license and insurance form ready,
b) Try to outrun them by driving the wrong way on the 405,
c) Have your video camera ready and provoke them to attack, thus ensuring yourself of a hefty lawsuit
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