Name:
(_) 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:
(_) Sister
(_) Brother
(_) Aunt
(_) Uncle
(_) Cousin
(_) Mother
(_) Father
(_) Son
(_) Daughter
(_) Pet

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?

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
____ bedroom
____ bathroom
____ kitchen
____ shed

Model and year of your pickup: _____________ 194_

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

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

Color of teeth:
(_)Yellow
(_)Brownish-Yellow
(_)Brown
(_)Black
(_)N/A

Brand of chewing tobacco you prefer:

How far is your home from a paved road?
(_)1 mile
(_)2 miles
(_)don't know