Personal Information:

      Name___________  Nickname______________  CB Handle___________

      Yore Mama______________  Yore Daddy (if known)________________

      Spouse's Name_________________

      Relationship to spouse:
      ___Sister  ____Brother  ____Mother ____Father ___Pet  ___Aunt

      Occupation: ___Unemployed Mechanic  ___Gun Show Dealer  ___Skinhead

      Number of Children in Household___
      Number that are yours___

      Circle Highest Level of Education: 1  2  3  4

      How Far is Your Mobile Home From a Paved Road: ___1mi. __5 mi. ___?

      Number of Times You Have Survived a Tornado: ___

      Number of Vehicles Owned___ Number on Cement Blocks___

      Truck Equipment:
      ___Gun Rack  ___Pit Bull  ___Spit Cup  ___Fuzzy Dice ___Rebel Flag
      ___Naked Woman Mudflaps  ___NWO and/or NRA sticker

      Weapons Owned: ___Tire Iron  ___Pick Handle  ___Beer Bottle

      Number of Dogs Owned: ___

      Number of Homemade Tattoo: ___

      Which of the Following Appliances are in your Front Yard:
      ___Friggerator  ___Heatin Stove  ___Warsher  ___TV  ___Freezer

      How Many of the Above Appliances Work: ___

      Fav-o-rite Recreation:
      ___Drinkin  ___Cow Chip Throwin  ___Possum Huntin ___Crawdad Hunti
      ___Spittin Backy  ___Scratchin  ___Watchin Wrasslin

      If You Can Read, Which Magazines Do You Prefer:
      ___Soap Opera Digest ___Rifle and Shotgun  ___NWA  ___TV Guide
      ___National Enquirer ___True Confessions

      Which Stinks Worse: ___Hogpen  ___Outhouse  ___Spouse

      Can You Spell Your Last Name:___Yup  ___Nope

      Can You Remember Your Last Name: ___Yup  ___Nope

      Have You Ever Stayed Sober for More Than One Day: ___Yup  ___Nope

      Do You Know Any Words with More Than 4 Letters: ___Yup  ___Nope

      Which is Correct A: ___"I Seed Him" or B:___"I Seen Him"

      How Many Cartons of Cigarettes Do You Smoke a Day? ___

      Math Test:   How Many Food Stamps Do the Following Cost?
      ___Six Pack  ___Ciggies  ___Shotgun Shells  ___Backy   ___Prostitute

      Number of Times You've Seen: ___a UFO ___ Elvis ___Elvis in a UFO

      Health Questionnaire: Which of the Following Do You Have?
      ___Head Lice  ___B.O.  ___Crabs  ___Runny Nose  ___Boils

      Can You Remember the Last Time You Bathed? ___Yup  ___Nope

      Color of Teeth: ___Yellow  ___Brown  ___Black ___N/A

      I hereby swear this is the trooth and sign my "X" on _________19__

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