Last name: ________________
              (Check appropriate box)

              First name:                     First name:

              [_] Billy-Bob                   [_] Bobby-Sue
              [_] Billy-Joe                    [_] Bobby-Jo
              [_] Billy-Ray                   [_] Bobby-Ann
              [_] Billy-Sue                   [_] Bobby-Lee
              [_] Billy-Mae                  [_] Bobby-Ellen
              [_] Billy-Jack                  [_] Bobby-Beth Ann Sue

              Age: ____ (if unsure, guess)

              Sex: ____ M _____ F _____ Not sure

              Shoe Size: ____ Left ____ Right

              Occupation:
              [_] Farmer                      [_] Mechanic
              [_] Hair Dresser            [_] Waitress
              [_] Un-employed          [_] Dirty Politician

              Spouse's Name:          __________________________
              2nd Spouse's Name:      __________________________
              3rd Spouse's Name:      __________________________
              Spell S-P-O-U-S-E

              Relationship with spouse:
              [_] Sister                      [_] Aunt
              [_] Brother                   [_] Uncle
              [_] Mother                   [_] Son
              [_] Father                     [_] Daughter
              [_] Cousin                    [_] Pet

              Number of children living in household: ___
              Number of children living in shed:            ___
              Number of children 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)

              Vehicles you own and where you keep them:

              ___ 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
              ____ kitchen
              ____ bedroom            ____ bathroom ____ 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          [_] Armed and Ready!

              ___ 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

              How many teeth? ___
              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
              [_] What's a paved road?