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 Sue

 Age:            _______ (if unsure, guess)
 Sex:            ____ M  _____F  _____ Not sure
 Shoe Size:      ____ Left               ____ Right

 Occupation:
 [_] Farmer                  [_] Mechanic
 [_] Hair Dresser            [_] Waitress
 [_] 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 all that apply)
 [_] 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?
 (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
   How often do you bathe:
 [_] Weekly
 [_] Monthly
 [_] Not Applicable

 How many teeth? ___

 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
 [_] > 2 miles
 [_] don't know