Last name: ________________
First name: (Check appropriate box)
(_)Billy-Bob (_)Billy-Joe (_)Billy-Ray (_)Billy-Sue (_) Billy-Mae (_)Billy-Jack
Age: ____ (if unsure, guess)
Sex: ____ M _____ F _____ Not sure
Shoe Size: ____ Left ____ Right
Occupation: (Check appropriate box)
(_)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: (Check as many boxes as necessary)
(_)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: ______
Father’s Name: _______________________ (If not sure, leave blank)
Mother’s Name: _______________________(If not sure, leave blank)
Education: 1 2 3 4 (Circle highest grade completed)
Do you (_)own or (_)rent your mobile home?
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 ____bedroom ____bathroom ____kitchen ____shed
Model year of your pickup: 196_
Do you have a gun rack?
(_)Yes (_)No; If no, please explain:
Newspapers/magazines you subscribe to:
(_)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
How far is your home from a paved road?
(_)1 mile (_)2 miles (_)don’t know (_)what paved road?
Leave a Reply