Last name: ________________
(Check appropriate box)
First name:                  First name:

[_] 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
[_] Un-employed              [_] 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? (Check appropriate box)

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 and year of your pickup: _____________ 194_

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

Newspapers/magazines you subscribe to:
[_] The 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

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