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