Name: _________________________ Stage name: ____________________

Agent: __________________________ Attorney: ____________________

Publicist ________________ Manicurist/hair stylist: ____________

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 ___

Occupation:

[ ] Lawyer [ ] Actor/Waiter [ ] Filmmaker/Self-employed [ ]Writer

[ ] Car Dealer [ ] Panhandler [ ] Agent [ ] Hooker/Transvestite

[ ] Other; please explain: ______________

Please indicate how many times you expect to have sex in car: ____

Please indicate how much you plan to spend for this sex.______

Brand of cell phone: __________.

(If you don't own a cell phone, please explain.)

Please check hair color:

Females: [ ] Blonde [ ] Platinum Blonde

Teenagers: [ ] Purple [ ] Blue

Skinhead Men: Please list shade of hair plugs.

Please check activities you perform while driving: (Check all that apply)

[ ] Eating a wrap [ ] Applying make-up [ ] Talking on the phone

[ ] Slapping kids in the back seat [ ] Having sex

[ ] Applying cellulite treatment to thighs [ ] Tanning

[ ] Snorting cocaine [ ] Watching TV [ ] Reading Variety

[ ] Surfing the Net via your 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 ____

If you are the victim of a car-jacking, 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).

Please indicate if you drive a:

a) Beamer,

b) Lexus,

c) Mercedes, or

d) Toyota.

If your answer is D, please add six to eight weeks to normal delivery time for your driver's license.

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, or

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, or

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) Zantax;

e) Viagra.

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?

d) reload before coming to a complete stop.