Jacuzzi Request Form
Distributed by the CPU Bureau of Intra-Complex Coordination and Communication:
Department of Forms, Vouchers, Memos, and Tongue Print Registration.

 

 

Section 1

Your name: *

Your email address: *

Security clearance:

Your Service Group:

Your Registered Mutation:

 

Section 2

Which model would you like to order?































Section 3

NOTE: Ultraviolet citizens can proceed directly to Section 4.

Did mind-altering drugs influence your decision to request this form?




Have you overdosed on Happy Pills in the last 72 hours?



Do you suffer from illusions of grandeur?




Do you even know how to spell Jacuzzi?




Did you know that IntSec were informed the moment you requested this form?




Do you think your next clone is likely to request this form too?




How best would you like your present clone to be remembered?



 

Section 4

B3 is best served with:








Other:

Box of recipient*

*Mandatory fields
**If not completed, report filed with IntSec

 

 


Issued by


High Programmer Fargmania
Chief Executive & Head Paper Pusher in Charge of Forms

CPU Division of Paranoia-Live.net, CPU Bureau of Intra-Complex Coordination and Communication: Department of Forms, Vouchers, Memos, and Tongue Print Registration.

 

Tongue Print Required
Please Lick Screen Here

 

For Office Use Only

Form filled out completely? (y/n)
  
Ultraviolet?
  
Security Clearance of Citizen
  

Termination?

  
Interrogation?
  
Surveillance?
  
Pass form around office for amusement of staff?  
Hygiene score
 

Recommendation

  Request Approved - Memwipe
  Request Declined - Memwipe
  Request Laughed at - Interrogation/Demotion
  Request Ignored - Food Vat Duty