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 Sue Age: ______ (if unsure, guess) Sex: _____M_____F_____Not sure Shoe Size: _____Left_____Right 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?[_] 200-400 miles[_] over 400 miles[_] what’s a miles?
