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 [ ] Skin-head Men: Please list shade of hair plugs ________________
Please indicate if you have Automobile Insurance: [ ] Yes [ ] No If Yes, please explain:
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 [ ] Applying cellulite treatment to thighs [ ] Tanning [X] Snorting cocaine (already checked for ease of application) [ ] Watching TV [ ] Reading Variety [ ] Surfing the net via laptop [ ] Reading a book or other Newspaper
Please indicate how many times: a) you expect to shoot at other drivers, _____ b) and 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 TV; 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 BMW, b) [ ] a Lexus, c) [ ] a Mercedes, d) [ ] a Cabriolet. If your answer is d, please add 6 to 8 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 d) [ ] pull out your video camera and obtain footage for Channel?
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? (Check all that apply.) a) [ ] Prozac; b) [ ] Zovirax; c) [ ] Lithium; d) [ ] Zanax.
If none, please explain: __________________.
Length of daily commute: a) [ ] 1 hour; b) [ ] 2 hours; c) [ ] 3 hours; d) [ ] 4 hours or more. If under 1 hour, please explain:
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 video camera ready and provoke them to attack, thus ensuring yourself of a hefty lawsuit?
