Last name: _____________________

First name: (Check appropriate box)

[ ] Billy-Bob
[ ] Billy-Joe
[ ] Billy-Ray
[ ] Billy-Sue
[ ] Billy-Mae
[ ] Billy-Jack
[ ] Bobby-Sue
[ ] Bobby-Jo
[ ] Bobby-Ann
[ ] Bobby-Lee
[ ] Bobby-Ellen
[ ] Bobby-Beth Ann Sue

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: (check all that apply)

[ ] Sister
[ ] Brother
[ ] Mother
[ ] Father
[ ] Cousin
[ ] Aunt
[ ] Uncle
[ ] Son
[ ] Daughter
[ ] Pet

Number of children living in household: ____
Number of children living in shed: ____
Number of children that are yours: ____

Mother's Name: _________________________ (If not sure, leave blank)
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)

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 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
___ Number of times you've been on Jerry Springer

How often do you bathe:

[] Weekly
[ ] Monthly
[ ] Not Applicable

How many teeth do you have? ____

Color of teeth:

[ ] Yellow
[ ] Brownish-Yellow
[ ] Brown
[ ] Black
[ ] Not Applicable

Brand of chewing tobacco you prefer:

[ ] Red-Man
[ ] Copenhagen

How far is your home from a paved road?

[ ] 2 miles
[ ] 3 miles
[ ] don't know