Personal Information

• Name:
• Nickname:
• CB Handle:
• Address (RFD):
• Daddy (if unknown, list 3 suspects):
• Neck Shade:
  ( ) Light Red
  ( ) Medium Red
  ( ) Dark Red
  ( ) Other
• Number of Teeth Exposed in Full Grin:
  Upper
  Lower
• Make of Pickup:
  Size of Tire:
• Hounds:
  Type:
  ( ) Blue Tick
  ( ) Beagle
  ( ) Black & Tan
  ( ) Other
• Length of Right Leg:
  Length of Left Leg:
• How Many Cars/Makes in Front Yard?:
  How Many on Blocks:
• How many kitchen appliances on Front Porch:
  on Back Porch:
• When and where was your last Elvis sighting:
• Do you wear mostly polyester pants with snags?
  ( )Yes ( ) No
• Do you own any shoes (not boots)?
  ( ) Yes ( ) No
• Are you married to any of the following (circle all that apply)?
  Sister   Cousin   Cousin's Sister   Aunt
  Other, explain:
• Does your wife weigh more than your pickup?
  ( ) Yes ( ) No
• Can you sign your own name and always spell it right?
  ( ) Yes ( ) No
• Have you EVER had more than one bath in a week?
  ( ) Yes ( ) No

Medical Information

• Do you have at least two of the following?
  ( ) B.O.
  ( ) Crabs
  ( ) Lice
  ( ) Scabies
  ( ) Bad Breath
  ( ) Fleas
  ( ) Tattoos
  ( ) Crossed Eyes
  ( ) Runny Nose
  
  
• Do you have:
  
  ( ) Green Teeth
  ( ) Brown Teeth
  ( ) Yellow Teeth
  ( ) Any Teeth
  ( ) # of teeth missing?

General Information

• Can you count past 10 with your shoes on?
  ( ) Yes ( ) No
• Past 21 with your shoes off and fly open?
  ( ) Yes ( ) No
• Favorite Weapon:
  ( ) Tire Iron
  ( ) Pick Handle
  ( ) Shotgun
  ( ) Log Chain
• Favorite Pasttime:
  ( ) Drinkin'
  ( ) Coon Huntin'
  ( ) Fishin'
  ( ) Other
• Truck Equipped with:
  ( ) 8-Track
  ( ) Fuzzbuster
  ( ) Gun Rack
  ( ) Roll Bar
  ( ) CB Radio
  ( ) Beer Cans
  ( ) Squirrel Tail
  ( ) Rebel Flag
• Favorite Vocalist:
  ( ) Willie Nelson
  ( ) Johnny Cash
  ( ) Elvis
  ( ) Conway Twitty
  ( ) Loretta Lynn
• Cap Emblems:
  ( ) Bud
  ( ) John Deere
  ( ) CAT
  ( ) Skoal
  ( ) Jack Daniels
• Bumper Stickers:
  ( ) Honk if you love Jesus
  ( ) Old Fart
  ( ) Dig Clams
• Memberships:
  ( ) NRA
  ( ) VFW
  ( ) KKK
  ( ) 700 Club
  ( ) BPOE

Your Signature (one X will do)
Date: