Last Name: ________________ 7b1d91231a87fb75e0054e886a0dea57
First name: (Check appropriate box):
(_) Billy-Bob
(_) Billy-Joe
(_) Billy-Ray
(_) Billy-Sue
(_) Billy-Mae
(_) Billy-Jack
(_) Billy
Age: ____, if known
Sex: ____ M _____ F _____ N/A
Shoe Size: ____ Left ____ Right
Occupation: (phonetic spellings available)
(_) Farmer
(_) Mechanic
(_) Hair Dresser
(_) Un-employed
Spouse’s Name: __________________________
Relationship with spouse:
(_) Sister
(_) Brother
(_) Aunt
(_) Uncle
(_) Cousin
(_) Mother
(_) Father
(_) Son
(_) Daughter
(_) Pet
(_) Livestock
Number of children living in household (If you can count) : ___
Number that are yours: ___
Mother’s Name: _______________________
Father’s Name: _______________________ (If not sure, leave blank)
Relation of mother to father: _________________
Education: 1 2 3 4 (Circle highest grade completed)
Do you (_)own or (_)rent your mobile home? (Check appropriate box)
Does it have wheels? (_)
How many tornadoes has it been through? (_)
___ 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
Number of shirts you own. (1) (2)
Number of shirts that are tank tops with motorcycles on them(_)
What does your foam hat say?
(_) “John Deer”
(_) “If I have anything to say to you I’ll fart”
(_) “I own a chevy truck”
(_) “Old Fart’s Wife”
(_) no longer readable due to filth
(_) you don’t know because you can’t read
Firearms you own and where you keep them:
____ truck
____ bedroom
____ bathroom
____ kitchen
____ shed
____ church benches (for when father speaks of the sins of incest)
Model and year of your pickup: _____________ 194_
How many deer have you struck with it? (_)
Do you have a gun rack?
(_) Yes (_) No; please explain:
Have you been struck by lightning? (_)
How many times? (_)
While carrying a firearm? (_)
What flavors of aqua velva does the local bar serve on tap?
(_) springtime blue
(_) musk
(_) seaside green
How many of your family members are cross eyed? (__), (_)all.
Newspapers/magazines you subscribe to:
(_) The National Enquirer
(_) Hustler
(_) Soldier of Fortune
(_) 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
___ Number of times you’ve shot at Elvis in a UFO
___ Number of consecutive sober days (0,1,2,3, can’t remember)
Do you bathe? (_)Yes (_)No (_)Don’t recall
If so, how often do you bathe:
(_)Weekly
(_)Monthly
(_)Not Applicable
Color of teeth:
(_)Yellow
(_)Brownish-Yellow
(_)Brown
(_)Black
(_)No teeth
Brand of chewing tobacco you prefer:
(_)Red-Man
How far is your home from a paved road?
(_)1 mile
(_)2 miles
(_)don’t know
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