APPLICATION TO LIVE IN WEST VIRGINIA

Name:______________ Nickname:____________ CB Handle:____________

Address: (RFD):_________________________________________________

Daddy: (If unknown attach list of three suspects):_____________________

Mamma:_______________________________

Neck Shade: [] Light Red [] Medium Red [] Dark Red

Number of teeth exposed in full grin: Upper:______ Lower:________

Name of Pickup Owned:______________ Height of truck:__________

Truck Equipped with:
[] Gun Rack [] 4-Wheel Drive [] Confederate Flag [] Toothpick Holder
[] 8-Track [] Load of Wood [] Hijacker Shocks [] Mud-grip Tires
[] Big Dog [] Racoon Hide [] Dual CB Antenna [] Fuzz Buster
[] Spitoon [] Camper Top [] Mag Wheels [] Air Horns
[] Mud Flaps

Number of Empty Beer Cans on Floor Board of Pickup:_________

Bumper Stickers:
[] Eat More Possum [] Peanut Butter [] Honk if You Love Jesus
[] Wave if Youre Horny [] Redman Chewing Tobacco

Define the following (Must be 90% correct):
[] Grits [] Muscadine [] Cobbler [] Tater
[] Goobers [] Brogans [] Fatback [] Pig Skins
[] Collards [] Redeye Gravy [] Tote [] Pinto Beans
[] Sidemeat [] Sawmill Gravy [] Poke [] Turnip Salit
[] Chitlins [] Soppin Syrup [] Cracker [] Shit-on-Shingle
[] Ramps

Favorite Vocalist:
[] Donna Fargo [] Conway Twitty [] Loretta Lynn [] Hank Williams
[] Elvis [] Slim Whitman [] Tammy Wynette [] Porter Wagoner
[] Johnny Cash [] Willie Nelson [] George Jones [] Box Car Willie

Favorite Recreation:
[] Square Dancin [] Possum Huntin [] Skinny Dippin
[] Craw Daddin [] Gospel Singin [] 4-Wheelin
[] Drankin [] Bull Chip Throwin [] Blue Grass Conventions
[] Spitten backy [] Other

Weapons Owned:
[] Deer Rifle [] Bird Gun [] Varmit Rifle [] Sawed-off Shotgun
[] Tire Iron [] Pick Handle [] Log Chain [] Power (chain) saw

Number of Hound Dogs:___ Type: [] Blue Tick [] Black & Tan [] Beagle

Emblem: [] John Deere [] CAT [] Budweiser [] McCullock Chain Saw
[] PBR [] NAPA [] Coors [] Skoals

Number of Weeks Unemployed:_____
Number of Welfare Checks Received:_____

Number of Dependents (Legal):______ (Claimed):______

Memberships:
[] KKK [] NRA [] Moose [] PTL Club [] VFW [] American Legion
[] Bass Club [] United Sons/Daughters of the Confederacy

Length of Left Leg:______ Length of Right Leg:______

Does your truck contain some part painted the official state color,
Primer Red?______

How many cars do you have jacked up on blocks in your front yard?______

How many kitchen appliances (working or not) will you keep on your front
porch?______

Will you be a part of the West Virginia Intelligentsia with a measurable
IQ?______

Do you wear mostly double knit polyester pants with snags?______

Do you own any shoes, if so how many? ______
What year did you last purchase shoes? ______

Are you married to any of the following?
[] Sister [] Cousin [] Sow Do you know her name? ______

Does your wife weigh more than your pickup?______

Can you sign your name and get the spelling right every time?______

Have you ever stayed sober for a whole weekend?______

Can you count: Past 10 with your shoes on? ______
To 21 with your fly up? ______

Medical Information:
Do you have at least 2 of the following:
[] BO [] Crabs [] Head Lice [] Bad Breath
[] Scabies [] Trench Mouth [] Runny Nose

Do you know any words that have more than 4 letters?______

Have you EVER had more than one bath in a week? ______