November 25, 200817 yr 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-Ann 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 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? 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 of your pickup: _____________ Year pickup produced: 194____ Do you have a gun rack? [_] Yes [_] No; If no, please explain:_________________________ Newspapers/magazines you subscribe to: [_] The National Enquirer [_] The Globe [_] MAXIM [_] TV Guide [_] Soap World [_] 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
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