Age: ____ (if unsure, guess)
Sex: ____ M _____ F _____ Not sure
Shoe Size: ____ Left ____ Right
Occupation:
[_] Farmer [_] Mechanic [_] Hair Dresser [_] Waitress
[_] Unemployed [_] 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: _____________ 196_
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?
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