Name: ________________
(last) | (_) Billy-Bob
(_) Billy-Joe
(_) Billy-Ray
(_) Billy-Sue
(_) Billy-Mae
(_) Billy-Jack
(Check appropriate box)
|
Age: ____
Sex: ____ M _____ F _____ N/A
Shoe Size: ____ Left ____ Right
Occupation:
(_) Farmer
(_) Mechanic
(_) Hair Dresser
(_) Un-employed
Spouse's Name: __________________________
Relationship with spouse:
(_) Sister
(_) Brother
(_) Aunt
(_) Uncle
(_) Cousin
(_) Mother
(_) Father
(_) Son
(_) Daughter
(_) Pet
Number of children living in household: ___
Number that are yours: ___
Mother's Name: _______________________
Father's Name: _______________________ (If not sure, leave blank)
Education: 1 2 3 4 (Circle highest grade completed)
Can you count to 21 and keep your fly up? (_)yes (_)no
Do you (_)own or (_)rent your mobile home? (Check appropriate box)
___ 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 and year of your pickup: _____________ 194_
Do you have a gun rack?
(_) Yes (_) No; please explain:
Newspapers/magazines you subscribe to:
(_) The National Enquirer
(_) Weekly World News
(_) 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
