- Name: (Check appropriate box)
____Billy-Bob
____Billy-Joe
____Billy-Ray
____Billy-Sue
____Billy-Mae
____Billy-Jack - Age: ____
- Sex: ____ M _____ F _____ N/A
- Shoe Size: ____ Left ____ Right
- Occupation:
____Farmer
____Mechanic
____Hair Dresser
____Un-employed - Spouse’s Name: __________________________
- Relationship with spouse:
- 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)
- ____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 - Model and year of your pickup: _____________ 194__
- Firearms you own and where you keep them:
____truck
____bedroom
____bathroom
____kitchen
____shed - Do you have a gun rack?
____Yes
____No; please explain:_______________________________________________________ - Newspapers/magazines you subscribe to:
____The National Enquirer
____The Globe
____TV Guide
____Soap Opera Digest
____Rifle and Shotgun - How many times have you:
____Seen a UFO?
____Been abducted by evil space aliens?
____Seen Elvis?
____Seen Elvis in a UFO? - How often do you bathe:
____Weekly
____Monthly
____Not Applicable - Color of teeth:
____Yellow
____Brownish-Yellow
____Brown
____Black
____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
____what’s a road?
____Sister
____Brother
____Aunt
____Uncle
____Cousin
____Mother
____Father
____Son
____Daughter
____Pet