Last Name: _________________________

First Name:
____ Billy-Bob
____ Billy-Joe
____ Billy-Ray
____ Billy-Sue
____ Billy-Mae
____ Billy-Jack
(Check appropriate box)

Age: ____

Sex: ____ M ____ F _____ N/A

Shoe Size: ____ Left ____ Right

CB Handle: _____________________

Occupation:
____ Farmer
____ Mechanic
____ Hair Dresser
____ Un-employed
____ Coal Miner

Spouse's Name: __________________________

Relationship with spouse:
____ Sister
____ Brother
____ Aunt
____ Uncle
____ Cousin
____ Mother
____ Father
____ Son
____ Daughter
____ Pet

Number of children living in household: ___

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? (Check appropriate box)

Vehicles:
____ 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
____ Number of refrigerators on front porch

Firearms you own and where you keep them:
____ truck
____ bedroom
____ bathroom
____ kitchen
____ shed

Model and year of your pickup: _____________ 194_
Number of empty beer cans on floorboard or in bed of pickup: _________

Newspapers/magazines you subscribe to:
____ The National Enquirer
____ The Globe
____ TV Guide
____ Soap Opera Digest
____ Gun World

____ 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
____ Holidays
____ Not Applicable

Color of teeth:
____ Yellow
____ Brownish-Yellow
____ Brown
____ Black
____ No teeth
____ N/A

Brand of chewing tobacco you prefer:
____ Red-Man

How far is your home from a paved road?
____ 1 mile
____ 2 miles
____ don't know
____ can't get there from here

Reason for continued residence in West Virginia:
____ can't bear to leave brother's behind
____ daddy won't give me my pants back
____ liberal wife beating laws

Bumper Stickers:
____ Eat more Possum
____ My other car is a piece of shit too
____ Honk if you love Jesus
____ If you ain't a cowboy, you ain't shit
____ Red-man Chewing Tobacco
____ Wave if you're horny

Favorite Recreation:
____ Square Dancin'
____ Possum Huntin'
____ Skinny Dippin'
____ Craw Daddin'
____ Gospel Singin'
____ 4-Wheelin'
____ Drankin'
____ Spittin' Backy
____ Bill Chip Trowin'
____ Honky Tonkin'
____ Noodlin'
____ Other

Number of Dogs: ____

Type:
____ Blue Tick
____ Beagle
____ Black & Tan
____ Bird Dawg

Cap Emblem:
____ John Deere
____ McCulloch Chain Saws
____ Budweiser
____ Vo-Tech
____ Skoal
____ Coors
____ NAPA
____ Smile if you're Not Wearing Underwear

Memberships:
____ KKK
____ NRA
____ Moose
____ PTL Club
____ AA
____ Bass Club
____ VFW
____ Quiltin' Bee
____ American Legion
____ United Sons/Daughters of the Confederacy
____ John Birch Society

Medical Information:

Do you have at least two of the following:
____ B.O.
____ Crabs
____ Head Lice
____ Rabies
____ Trench Mouth
____ Runny Nose
____ Bad Breath
____ Chafing