California Residency Form

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Name: ____________________________________ (Feel free to use popular nicknames, such as "Moon Beam", "Dweezil", "Moon Unit" "Capt. Trips", etc.)

Age: _____

Inner Child's Age: ___

Age in Dog Years: ____

Age as told to you in a vision by ancient Mayan calendar: ____

Sex: _____ M _____ F _____ Hermaphrodite _____ Still working it out in therapy

Footwear: ____ Birkenstocks ____ Barefoot

Condition of Feet: ____ Wash Daily ____ Wash Weekly ____ Like, whenever I get to the beach, man...

Occupation: ___ Massage Therapist ___ Astral Counsel ___ Pet Psychologist ___ Channeler of the Dead (real dead, not merely Grateful) ___ Follower of the Dead, (Grateful) ___ Tie-dye vendor at Dead Shows ___ Vendor of "nice hot, fresh veggie burritos" at concerts ___ Cooking up a scheme to channel Jerry Garcia ___ Assistant to Shirley MacLaine ___ Rent-A-Mob protester ___ Purveyor of Fine Herbal Remedies ___ Panhandler claiming to be a veteran ___ Professional Guest on Ricki Lake ___ LA rock star groupie ___ Bottom-feeding LA lawyer ___ Professional Emotional Victim

Name(s) of Significant Other(s): ________________________________

Relationship(s) of Significant Other(s): ____ Astral Soulmate ____ One-night stand from the protest rally who stayed because the rent was cheap ____ My dog's massage therapist ____ "Just Friends" ____ They're really not that significant, but I'll try to claim them as tax deduction(s)

Number of Children in Commune: _____

Number of Inner Children In Commune: _____

Number of your Inner Children which have been molested by one of Roseanne's multiple personalities: ____

Mother's Name: ____________________

Father's Name: ____________________

Where were you were conceived: ____ Woodstock ____ Monterey ____ Under the stars on in the commune's hot tub ____ In the back of a VW micro-bus on the way to a Dead show

Name of book exposing your parents as inner-child abusers: ______________

Number of copies sold: ____

Number of Wind Chimes Owned: ____

Number of times you've given yourself a concussion by hitting head on wind chimes: ___

Number of time you've channeled dead space aliens: ____

Number of times a space alien has copped a feel off you: ____

Talk Shows on Which You Make a Regular Appearance: ____ Donahue ____ Ricki Lake ____ Geraldo ____ Sally Jesse ____ The morning news' surf report

Number of times you've eaten your surfboard: ____

Above, while still in parking lot after tripping on your sandals: ____

Number of Grateful Dead concerts attended: ____ (if all, enter "on tour")

Number of bongs you own: ____

Number of times you've drunk your bong water because the weed ran out: ____

Political Party Affiliation: (Choose as many as you have personalities) ____ Green Party ____ American Communist Party ____ Socialist Party ____ New Age Astral Party (channeling the spirits of dead Romans) ____ Hemp Party ____ The Party-Hearty Party ____ Inner Child Abuse Hotline Party ____ New Age Goddess Party

How far is your home from the waterline: ___ Miles ___ Yards ___ Feet ___ I like to wake up with sand in my nose and seaweed in my teeth, in true harmony with nature as it washes up my nose

Number of surfboards owned: ____

Number of seconds you can talk without using the words "totally", "like", "man" and "fer shure": ____ (enter, like 0, if you, like, totally don't know)

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smiley 5.1 PG

submitted: 1+ years ago

viewed: 2,142 times

categories: ethnic, race, international

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C3CXN_California Residency Form

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