Name: ________________ (_) Billy-Bob
(last) (_) Billy-Joe
(_) Billy-Ray
(_) Billy-Sue
(_) Billy-Mae
(_) Billy-Jack
(_) Billy-Jefferson
(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_

Newspapers/magazines you subscribe to:
(_)The National Enquirer
(_)The Globe
(_)TV Guide
(_)Soap Opera Digest

___ 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