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
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 with spouse:
[_] Sister [_] Aunt
[_] Brother
[_] Uncle
[_] Mother
[_] Son
[_] Father
[_] Daughter
[_] Cousin
[_] Pet
Number of children living in household: ___
Number of children living in shed: ___
Number of children 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?
Vehicles you own and where you keep them:
___ Total number of vehicles 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
Firearms you own and where you keep them:
____ truck
____ kitchen
____ bedroom
____ bathroom
____ shed
Model of your pickup: _____________
Year pickup produced: 194____
Do you have a gun rack?
[_] Yes [_] No; If no, please explain:_________________________
Newspapers/magazines you subscribe to:
[_] The National Enquirer
[_] The Globe
[_] MAXIM
[_] TV Guide
[_] Soap World
[_] 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
How many teeth? ___
Color of teeth:
[_] Yellow
[_] Brownish-Yellow
[_] Brown
[_] Black
[_] N/A
Brand of chewing tobacco you prefer:
[_] Red-Man
How far is your home from a paved road?
[_] 1 mile
[_] 2 miles
[_] don't know
