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 hair color:

Females: [ ] Blonde [ ] Platinum Blonde

Teenagers: [ ] Purple [ ] Blue [ ] Skinhead

Please indicate 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 magazine
[ ] 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: _____

Please indicate your 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: _______________________________

What is the length of your daily commute?

a) 1 hour _____
b) 2 hours _____
c) 3 hours _____
d) 4 hours or more _____

TEST (Please indicate the correct answer):

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 TV in a high-speed chase
c) Call your attorney and discuss a lawsuit against the cellular phone company for your 911 call not going through
d) Call your therapist
e) None of the above (South Central residents only)

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 4

In the event 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

When stopped by police, you should:

a) Pull over and have your driver's license and insurance card 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, ensuring yourself of a hefty lawsuit