Note: this application will be considered imcomplete and thereby rejected without a full and complete financial disclosure statement and a complete medical history from your physician.

Name: _____________ Birth Date: __________
SS#: _____________
Address: ________________________ City: ________
State: ____ Zip: ______

Do you have one male and one female parent? Y/N If "no" explain ______

Do you own a Van? _______ If yes, stop here and leave premises

In fifty words or less, what does the word "NO" mean to you?
___________________________________________________

In fifty words or less, What does the word "LATE" mean to you?

___________________________________________________

Name of church you attend ______ # times addended last year____
Funeral Home preference________ Cemetery Preference _______

Answer the following completely (all answers cofidential, parent use only)

1. If I were ever shot, the last place on my body I would want to be
wounded is ______________________________.
2. If I were ever beaten, the last bone I would wand broken is my:     ____________.
3. A woman's place is ______________________________.
4. When I first meat a girl, the first thing I notice is her ______.
5. The one thing I hope this application doesn't ask is _________
_________________________________________________
6. What do you want to be if you grow up? _________________

I swear that all information I have supplied is true to the best of my
knowledge, under penalyt of death and dismemberment.

_________________________________________
Applicant's Signature

DO NOT WRITE BELOW LINE --- PARENTAL USE ONLY
____________________________________________________

Appearance:
Preppy ____ Normal _____ Hard Rock ______
Intelligence:
Carl Sagan _____ David Letterman _____ Beavis & Butthead _____

Application: Accepted / Rejected Date: ___________________