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

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 to spouse:
[_] Sister [_] Aunt
[_] Brother [_] Uncle
[_] Mother [_] Son
[_] Father [_] Daughter
[_] Cousin [_] Pet

Number of children living in household: ___
Number of children living in shed: ___
Number 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)


___ 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

Where you keep them firearms:
____ 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 read:
[_] 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

Color of teeth:
[_] Yellow [_] Brownish-Yellow
[_] Brown [_] Black
[_]N/A [_] Teeth?

Brand of chewing tobacco you prefer: [_] Red-Man

How far is your home from a paved road?
[_] 1 mile [_] 2 miles [_] don't know [_]paved road ?