Page:Principia Discordia (1970).djvu/26



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 e. None of the above f. Other--be specific!

3. Name Holy Name

Address

If temporary, also give an address from which mail can be forwarded

4. Description: Born: undefined undefined yes undefined undefined no Eyes: undefined undefined 2 undefined undefined other Height: ........fl. oz. Last time you had a haircut: Reason: Race: undefined undefined horse undefined undefined 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 have been fired. Medical: On a seperate sheet labeled “confidential,”’ list all major psychotic episodes experienced within the last 24 hours

6. Sneaky questions to establish personality traits

I would rather a. live in an outhouse b. play in a rock group c. eat caterpillers. I wear obscene tattoos because

I have ceased raping little children undefined undefined yes undefined undefined no -- reason

7. SELF-PORTRAIT

LICK HERE!

(You may be one of the lucky 25)

Rev. Mungo For Office Use Only- acc. rej. burned