Application For Membership
In the Erisian movement of the DISCORDIAN SOCIETY

1. Today's date
   Yesterday's date

2. Purpose of this application/membership in:

3. Name
   Holy Name
(If temporary, also give an address from
which mail can be forwarded)
4. Description:
Born: Yes No    -    Eyes: Two Other
Height: fl. oz.
Last time you had a haircut:
Race: Horse Human
5. History:
Education - highest grade completed
Professional: On another ream of paper list every job since 1937 from which you have been fired.

Medical: On a separate sheet labeled "confidential", list all major psychic psychotic episodes experienced within the last 24 hours.

6. Sneaky questions to establish personality traits
I would rather
I wear obscene tattoos because
I have ceased raping little children :- Yes No
7. Self Portrait

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