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, just guess)
Sex: ____M____F____not sure
Shoe size: ____left ____right
Occupation:
[_] Farmer [_] Mechanic
[_] Hairdresser [_] Waitress
[_] Un-employed [_] Dirty-politition
Spouse's name:______________________
2nd spouse's name:_________________________
3rd spouse's name:___________________________
Lover's name:_________________________
2nd lover's name:________________________
Relationship with spouse:
[_] sister [_] Aunt
[_] Brother [_] uncle
[_] Mother [_] Son
[_] Father [_] Daughter
[_] Cousin [_] Pet
No. of children living in household:_____________
No. of children living in shed:________________
No. of them that are yours:________________
Mother's name:_____________________
Father's name:___________________(if unsure, leave blank)
Education: 1 2 3 4 (circle highest grade completed)
Do you [_] Own or [_] Rent your mobile home?
Modela nd year of your pick-up:__________194_
Do you have a gun rack? [_] yes [_]no (if no, please explain)
