Name: ___________________________
Stage name: __________________________
Agent's Name: __________________________
Attorney's Name: _______________________
[ ] male [ ] female [ ] formerly male [ ] formerly female [ ] both [ ] neither
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 [ ]
Actual Age: _____ Admitted Age: _____
Actual Height: _____ Admitted Height: _____
Actual Weight: _____ Admitted Weight: _____
Eyecolor: _____
Do you wear contact lenses? [ ] Yes [ ] No
Contact Lense Color(s)/Design(s): _______________
Please check hair color:
Females:
[ ] Blonde [ ] Platinum Blonde [ ] Dark Cherry Red
Teenagers:
[ ] Purple [ ] Blue [ ] Skin-head [ ] WhiteTip
Men:
Please list shade of hair plugs ________________
[ ] Lawyer
[ ] Actor/Waiter
[ ] Film-maker/Self-employed
[ ] Writer
[ ] Agent
[ ] Car Dealer
[ ] Cell phone Dealer
[ ] Drug Dealer
[ ] Pan-handler
[ ] Gang Member
[ ] Hooker/Transvestite
[ ] Dog Caregiver
[ ] Other; please explain:
___________________________
[ ] Eating Disorder
[ ] Psychotic Disorder
[ ] Schizophrenia
[ ] Drug Addiction
[ ] Others: ________________________________
[ ] sipping latte
[ ] eating a wrap
[ ] applying make-up
[ ] talking on the phone
[ ] rehearsing lines
[ ] 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 newspaper
Please list brand of cell phone:
___________________________
(If you don't own a cell phone, please explain.)
___________________________
___________________________
___________________________
___________________________
[ ] Yes [ ] No
If Yes, please explain: ___________________________ ___________________________ ___________________________ ___________________________
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