| Last
name:_________________________ (If unsure, guess) |
|
| First name: (Check as many as apply) |
|
| [ ] 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: (Check as many as apply) |
|
| [ ] Farmer | [ ] Mechanic |
| [ ] Hair Dresser | [ ] Waitress |
| [ ] Unemployed | [ ] Dirty Politician |
| Spouse's Name:___________________________ | |
| 2nd Spouse's Name:___________________________ | |
| 3rd Spouse's Name:___________________________ | |
| Spell S-P-O-U-S-E___________________________ | |
| Relationship with
spouse: (Check as many as 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 5 6 7 (Circle highest grade completed) |
|
| Do you: | |
| [ ] Own | [ ] 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 ___ | Living room ___ |
| Model and year of your pickup:_____________ 196___ | |
| 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 | [ ] Armed and Ready! |
| 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 |
| [ ] Yearly | [ ] N/A |
| How many teeth? ___ | |
| Color of teeth: | |
| [ ] Yellow | [ ] Brownish-Yellow |
| [ ] Brown | [ ] Black |
| [ ] N/A | |
| Brand of chewing tobacco you prefer: | |
| [ ]Skoal | [ ] Red-Man |
| [ ]Copenhagen | |
| How far is your home from a paved road? | |
| [ ] 1 mile | [ ] 2 miles |
| [ ] Over 2 miles | [ ] What's a paved road? |
| Signature: | |
|
______________________________________________ (X will do) |
|
| Witness: | |
|
______________________________________________ (If signed with X) |
|
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