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 miles0