- Name: _____________________________________________________________________
- Ethnic Information: (voluntary)
____ Eskimo
____ American Indian
____ Hispanic
____ Asian
____ African-American
____ American-African
____ Black-American
____ Other Group With A Long History Of Oppression By White Males
(specify, so we can help you form a political action group)
___________________________________________________ - Type of Cars Owned (pick two):
____ SAAB
____ Volvo
____ BMW
____ Mercedes
____ Honda - You don’t own any *American* cars, do you?
____ NO - Car Equipment:
____ Blaupunkt
____ Passport
____ Escort
____ Vuarnet Sunglasses
____ Stash
____ CD
____ GPS
____ Cellular Phone
____ Ski Rack
____ Bicycle Rack
____ Wine Rack - Bumper Stickers:
____ “You can’t hug a child with nuclear arms”
____ “Greenpeace”
____ “Obama/Biden”
____ “Save the Whales”
____ “Farms not Arms” - Sexual Orientation:
____ Gay
____ Lesbian
____ Other(note: failure to give the proper answer to the above means you can’t live in certain towns on the Cape, or get elected to Congress)
- Favorite Cause:
____ Whales
____ Baby Seals
____ Snail Darter
Total given to these causes in the last 12 months: ________________ - Favorite Drugs:
____ Crack
____ Coke
____ Grass
____ Kitty’s Diet Plan - Which of the Following Should be Banned? (check all that apply)
____ The Bomb
____ Handguns
____ All guns
____ Nuclear Power
____ Cigarettes
____ The NRA
____ Republicans - Which of the Following Should be Legalized?: (check all that apply)
____ Crack
____ Coke
____ Grass
____ Needles
____ Flag Burning - Favorite Beer:
____ Samuel Adams
____ Beck’s
____ Corona (w/lime)
____ Latest trendy brand - Favorite Politician:
____ Ted Kennedy
____ John Kennedy
____ Bobby Kennedy
____ Joe Kennedy - Club Memberships:
____ ACLU
____ Greenpeace
____ SDS
____ N.O.W.
____ A.F.S.C.M.E.
____ Billy Bulger Breakfast Club
____ Provincetown Boys Club
____ Bull-Dykes Kennel Club - Even though we can’t ever get any more power from Hydro-Quebec, don’t you
think that Seabrook should remain closed forever?
____ YES - Don’t you think that the people in the Midwest should stop dropping acid rain on our vacation homes in Vermont, even if it means that they all lose their jobs?
____ YES - How many watts (per channel, RMS) is your principal home stereo?
____ 100W
____ 200W
____ More than that - How many air conditioners do you have to help you through our long New England summers?:
____ 2
____ 3
____ 4
____ Central Air(note: Fewer than two A/C units may qualify you for state subsidies if you are a non-white unemployed Democrat)
- Favorite TV Show:
____ Once and Again
____ Providence
(extra space left due to new social awareness)