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
Number of 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 [_] 4×4 Weekly
[_] Hot Rods & Handguns
___ 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
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