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 firearms:
____ truck ____ kitchen
____ bedroom ____ bathroom
____ shed ____ all of the above
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
[] Other
How far is your home from a paved road?
[] 1 mile
[] 2 miles
[] don’t know
[] paved road?
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** unthinking respect for authority is the greatest enemy of Truth! **