(Check appropriate box) First name: First name:

[_] Billy-Bob [_] Bobby-Sue [_] Billy-Joe [_] Bobby-Jo [_] Billy-Ray [_] Bobby-Ann [_] Billy-Sue [_] Bobby-Lee [_] Billy-Mae [_] Bobby-Ellen [_] Billy-Jack [_] Bobby-Beth Ann Sue

Age: ____ (if unsure, guess) Sex: ____ M _____ F _____ Not sure Shoe Size: ____ Left ____ Right

Occupation: [_] Farmer [_] Mechanic [_] Hair Dresser [_] Waitress [_] Un-employed [_] Dirty Politician

Spouse's Name: __________________________ 2nd Spouse's Name: __________________________ 3rd Spouse's Name: __________________________ Lover's Name: __________________________ 2nd Lover's Name: __________________________ Relationship with spouse: [_] Sister [_] Aunt [_] Brother [_] Uncle [_] Mother [_] Son [_] Father [_] Daughter [_] Cousin [_] Pet

Number of children living in household: ___ Number of children living in shed: ___ Number of children 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 you own and where you keep them:

___ 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

Firearms you own and where you keep them:

____ truck ____ kitchen ____ bedroom ____ bathroom ____ shed

Model and year of your pickup: _____________ 194_

Do you have a gun rack? [_] Yes [_] No; If no, please explain:

Newspapers/magazines you subscribe to:

[_] The National Enquirer [_] The Globe [_] TV Guide [_] Soap Opera Digest [_] Rifle and Shotgun

___ 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 [_] Not Applicable

How many teeth? ___ 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