Last name: ________________
First name:
(_) Billy-Bob
(_) Billy-Ron
(_) Billy-Joe
(_) Billy-Ray
(_) Billy-Sue
(_) Billy-Mae
(_) Billy-Jack
(_) Billy-Elvis
(Check appropriate box)
Age: ____
Sex: ____ M _____ F _____ not sure______
Shoe Size: ____ Left ____ Right
Occupation:
(_) Farmer
(_) Mechanic
(_) Hair Dresser
(_) Unemployed
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
Number of 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; 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
Color of teeth:
(_)Yellow
(_)Brownish-Yellow
(_)Brown
(_)Black
(_)N/A
Brand of chewing tobacco you prefer:
(_)Red-Man
(_)Other
How far is your home from a paved road?
(_)1 mile
(_)2 miles
(_)don't know
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