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
If temporary, also give an address from which mail
can be forwarded
Born: | | yes | | no
Eyes: | | 2 | | other
Height: .....fl. oz.
Last time you had a haircut:
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 . . .