Last name: ________________

First name:
(_) Billy-Bob
(_) Billy-Joe
(_) Billy-Ray
(_) Billy-Sue
(_) Billy-Mae
(_) Billy-Jack
(Check appropriate box) 

Age: ____ (if unsure, guess) 

Sex: ____ M _____ F _____ Not sure

Shoe Size: ____ Left ____ Right 

Occupation:
(_) Farmer
(_) Mechanic
(_) Hair Dresser
(_) 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
(_) Brother
(_) Aunt
(_) Uncle
(_) Cousin
(_) Mother
(_) Father
(_) Son
(_) Daughter
(_) 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 

How many firearms you own _____ and where you keep them:
____ truck
____ bedroom
____ bathroom
____ kitchen
____ shed
(Check all that apply)

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

Color of teeth:
(_)Yellow
(_)Brownish-Yellow
(_)Brown
(_)Black
(_)N/A

Brand of chewing tobacco you prefer:
(_)Red-Man
(_)Skoal

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