Section 1

*Name:
Date and time:
Service firm:
Housing unit:
Per annum radiation exposure:

Section 2

INSTRUCTIONS: Answer all questions fully and completely. Except where indicated, check only one response for multiple choice questions. If you have speculations s to the source of your mutation, include them on the back of this form. Practice good penmanship. Trust The Computer. Failure to obey is treason.

Having a mutation makes me feel (check all that apply):

Happy	Morose	Satisfied
Unhappy	Powerful	Very worried
Enthusiastic	Kind of tingly	Inferior
Cunning	Apathetic	Despairing

I need to register my mutation because (check all that apply):

I love mutants	The Computer loves mutants
I am being blackmailed	I dare not disobey
I lost a really dumb bet	Honesty is the best policy
I have a death wish	My head is going to explode
My awesome might should be used for the good of all Alpha Complex

It takes me to eat a HappyTummy Energy Bar.

YesNo   I have been on the premises of a nuclear reactor within the last three months.

YesNo   I have watched more than two complete episodes of The Best Good Happy Sector Hour.

YesNo   I have heard of the secret society known as 'Psion.'

YesNo   If given the choice, I would opt to terminate myself in hopes that my next clone would not suffer from this mutation.

YesNo   My mutation is powerful enough to possibly harm the citizens, social institutions and/or property of Alpha Complex.

If 'yes,' why should you be permitted to live on as a menace to all who surround you?    If 'no,' how will your mutation be of any use to Alpha Complex?

What can you possibly hope to accomplish that would make up for the mere fact of your blighted existence?

How long will it take you to do this?

Describe your mutation. Include specific examples with time, date, location and witnesses.

Section 3

Please list all ciitzens you have damaged, injured or inconvenienced with your mutation. Continue on reverse if necessary.
	Citizen Date and Time Location Offense

The average handling time for this form is between THREE DAYS and EIGHTEEN MONTHS. Resubmitting an identical copy of this form will not expedite processing in any way. If you need to alter or amend any information on this form, resubmit it with an attached Application Modification Rider (993-51-Z8854). Until this form has been duly and fully processed, you are not authorized to use your purported mutation in any way whatsoever. If your application for Registered Mutant status is approved, you will be retroactively subject to all requirements and regulations thereof, in accordance with section 72 of the Laws of Alpha Complex ed. 39/B.3.9.

Section 4

Box of recipient*

*Mandatory fields

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.

Copyright (C)1983, 1987, 2005 Eric Goldberg and Greg Costikyan. PARANOIA is a trademark of Eric Goldberg and Greg Costikyan. All Rights Reserved.