Occupation:
[_] Farmer       [_] Mechanic
[_] Hair Dresser [_] Waitress
[_] Unemployed   [_] Dirty Politician

Spouse's Name________________________
2nd Spouse's Name:  _________________
3rd Spouse's Name:  _________________
Lover's Name: _______________________
2nd Lover's Name: ___________________
Relationship to spouse:
[_] Sister  [_] Aunt
[_] Brother [_] Uncle
[_] Mother  [_] Son
[_] Father  [_] Daughter
[_] Cousin  [_] Pet

Number of children living in household:  _____ 
Number of children living in shed:  ____ 
Number 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?
___ Total number of vehicles that 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

Where your firearms are kept:
[_] 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:
[_] 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

Color of teeth:
[_] Yellow  [_] Brownish-Yellow
[_] Brown   [_] Black
[_] N/A     ___ How many?

Brand of chewing tobacco you prefer:  [_] Red-Man

How far is your home from a paved road?
[_] 1 mile
[_] 2 miles
[_] don't know