Name: ________________  (_) Billy-Bob

               (last)        (_) Billy-Joe

                             (_) Billy-Ray

                             (_) Billy-Sue

                             (_) Billy-Mae

                             (_) Billy-Jack

                             (Check appropriate box)

 

     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?  (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

 

     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 Weekly Times

     (_) The Mercury

     (_) 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:

     (_)Red-Man

 

     How far is your home from a paved road?

     (_)1 mile

     (_)2 miles

     (_)don't know

     (_)what's a road?