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