Last name: ______________________

(Check the appropriate box)
First Name:
[ _ ] Bubba
[ _ ] Bobby-Sue
[ _ ] Bobby-Jo
[ _ ] Billy-Joe
[ _ ] Billy-Ray
[ _ ] Billy-Jack
[ _ ] Bobby-Lee
[ _ ] Bobby-Ellen
[ _ ] Bobby-Ann
[ _ ] Billy-Mae
[ _ ] Billy-Sue
[ _ ] Billy-Beth Sue Ellen

Age: ____ (if unsure, take a guess)

Sex: ____ M _____ F _____ Not sure

Shoe Size: ____ Left ____ Right

Occupation:
[ _ ] Mechanic
[ _ ] Waitress
[ _ ] Farmer
[ _ ] Hairdresser
[ _ ] Unemployed
[ _ ] Dirty Politician

Spouse's Name: _____________________________
2nd Spouse's Name: __________________________
3rd Spouse's Name: __________________________
Lover's Name: _______________________________
2nd Lover's Name: ____________________________

Relationship with Spouse:
[ _ ] Mother
[ _ ] Aunt
[ _ ] Daughter
[ _ ] Sister
[ _ ] Father
[ _ ] Uncle
[ _ ] Brother
[ _ ] Son
[ _ ] 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 unsure, 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 they are kept:
____ Truck
____ Bedroom
____ Kitchen
____ Bathroom
____ Shed

Model and year of your pickup: _____________ 194__

Number of road kills currently in your freezer?
[ _ ] 3
[ _ ] 5
[ _ ] 10 or more

Do you have a gun rack?
[ _ ] Yes [ _ ] No
If no, please explain: __________________________

Newspapers/magazines you subscribe to:
[ _ ] National Enquirer
[ _ ] TV Guide
[ _ ] The Globe
[ _ ] 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
[ _ ] Special Occasions (Birthdays, Anniversaries, Holidays, etc.)
[ _ ] Not applicable

How many teeth: ______
Color of Teeth:
[ _ ] Yellow
[ _ ] Brownish Yellow
[ _ ] Brown
[ _ ] Black
[ _ ] N/A

Brand of chewing tobacco you prefer: ___________