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

Spouses Name: __________________________
2nd Spouses Name: _________________________
3rd Spouses Name: _________________________
Lovers Name: ____________________________
2nd Lovers 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: ___

Mothers Name: _______________________
Fathers 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


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


How often do you bathe:

[_] Weekly
[_] Monthly
[_] Not Applicable

How many teeth? ___
Color of teeth:

[_] Yellow
[_] Brownish-Yellow
[_] Brown
[_] Black
[_] N/A


How far is your home from a paved road?

[_] 1 mile
[_] 2 miles
[_] dont know