Last name: _________________
First name:
(Check appropriate box)
[_] billy bob [_] Bobby-Sue
[_] Billy-Joe [_] Bobby-Jo
[_] Billy-Ray [_] Bobby-Ann
[_] Billy-Sue [_] Bobby-Lee
[_] Billy-Mae [_] Bobby-Ellen
[_] Billy-Jack [_] Bobby-Beth Ann Sue

Age: ______ (if unsure, guess)

Sex: _____M_____F_____Not sure

Shoe Size: _____Left_____Right

Occupation:
[_] Farmer [_] Mechanic
[_] Hair Dresser [_] Waitress
[_] Unemployed [_] Dirty Politician

Spouse’s Name_________________________
2nd Spouse’s Name: _________________
3rd Spouse’s Name: _________________

Lover’s Name: ________________________
2nd Lover’s Name: ___________________

Relationship to spouse:
[_] Sister [_] Aunt
[_] Brother [_] Uncle
[_] Mother [_] Son
[_] Father [_] Daughter
[_] Cousin [_] Pet

Number of children living in household: _____
Number of children living in shed: _____
Number that are yours: _____

Mother’s Name: ___________________
Father’s Name: ___________________ (If not sure, leave blank)

Education: 1 2 3 4 (Circle highest grade completed)

Do you [_] own or [_] rent your mobile home?
___ Total number of vehicles that you own
___ Number of vehicles that still crank
___ Number of vehicles in front yard
___ Number of vehicles in back yard
___ Number of vehicles on cement blocks

Where your firearms are kept:
[_] truck [_] kitchen
[_] bedroom [_] bathroom
[_] shed

Model and year of your pickup: _______ 194_

Do you have a gun rack?
[_] Yes [_] No; if no, please explain:
_____________________

Newspapers/magazines you subscribe to:
[_] National Enquirer [_] The Globe
[_] TV Guide [_] Soap Opera Digest
[_] Rifle and Shotgun

___ Number of times you’ve seen a UFO
___ Number of times you’ve seen Elvis
___ Number of times you’ve seen Elvis in a UFO

How often do you bathe:
[_] Weekly
[_] Monthly
[_] Not applicable

Color of teeth:
[_] Yellow [_] Brownish-Yellow
[_] Brown [_] Black
[_] N/A
How many?_____

Brand of chewing tobacco you prefer: [_] Red-Man

How far is your home from a paved road?
[_] 200-400 miles
[_] over 400 miles
[_] what’s a miles?