1.  Today’s date	   Yesterday’s date

2. Purpose of this application:   --membership in: 
a. Legion of Dynamic Discord         b. POEE    
c. Bavarian Illuminati     d. All of the above

3.  Name                    Holy Name
Address
If temporary, also give an address from which mail 
can be forwarded

4.  Description:    
Born:   |  | yes   |  | no        
Eyes:   |  | 2     |  | other       
Height:	.....fl. oz.   
Last time you had a haircut:                
Reason:
Race:  |  | horse    |  | human        
I.Q.:  150-200   200-250    250-300   over 300

5.  History:  Education - highest grade completed   
              1   2   3   4    5    6    over 6th

Professional:     On another ream of paper list every 
job since 1937 From which you’ve been fired. 
        
Medical:  On a separate sheet Labeled "confidential," 
list all major psychotic episodes experienced
Within the last 24 hours

6.  Sneaky question to establish personality traits
	I would rather a. live in an outhouse    
		       b. play in a rock group    
		       c. eat caterpillars.    
	I wear obscene tattoos because  . . . . . .  
	I have ceased raping little children    
		|  | yes   |  |  no -- reason  . . . 

5.	SELF-PORTRAIT