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: