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

Spouses Name_________________________

2nd Spouses Name: _________________

3rd Spouses Name: _________________

Lovers Name: ________________________

2nd Lovers 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: _____

Mothers Name: ___________________

Fathers 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 youve seen a UFO

___ Number of times youve seen Elvis

___ Number of times youve 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

[_] whats a miles?