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Name: ___________________ Stage name: ____________________ Agent: ___________________ Attorney: _______________________ Therapist name: _________________ 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 hair color: Females: < > Blonde < > Platinum Blonde Teenagers: < > Red < > Orange < > Green < > Purple < > Blue < > Skinhead
Please check activities you perform while driving: (Check all that apply) < > Eating < > Drinking Starbucks coffee < > Applying make-up < > Shaving (male or female) < > Talking on the phone < > Slapping kids in the back-seat < > Applying cellulite treatment to thighs < > Tanning Snorting cocaine (already checked for your convenience) < > Watching TV < > Reading Variety < > Surfing the net via laptop < > Discharging firearms / Reloading
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 carjacking, you should immediately: a) Call the police to report the crime. b) Call Channel 9 News to report the crime, then watch your car on the news in 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.
In the event of an earthquake, you should: 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 9.
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 f) Zoloft g) All of the above h) None of the above *If none, please explain: __________________.
Length of daily commute: a) Less than 1 hour b) 1 hour c) 2 hours d) 3 hours e) 4 hours or more * If less than 1 hour, please explain:____________________.
When stopped by police, you should: 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 Freeway. c) have your video camera ready and provoke them to attack, thus ensuring yourself of a hefty lawsuit.
When turning, you should always signal your intentions by: a) using your directional signals. b) what is a "directional signal"? c) waving firearm in the direction you wish to turn. d) using middle finger to indicate direction you wish to turn.
Which part of your car will wear out most often? a) the wiper blades b) the belts c) the horn d) bumper
The "bright" setting on your headlights is for: a) dark, poorly lit roads b) flashing to get the car ahead to move out of the way c) revenge! d) driving at night
Your rear view mirror is for: a) watching for approaching cars b) watching for approaching police cars c) checking your hair d) seeing how close you cut that jerk off
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