1. Last name: ________________
2. First name: (Check appropriate box)
(_) Billy-Bob (_) Billy-Joe (_) Billy-Ray (_) Billy-Sue (_) Billy-Mae (_) Billy-Jack
3. Age: ____
4. Sex: ____ M _____ F _____ not sure
5. Shoe Size: ____ Left ____ Right
6. Occupation:
(_) Farmer (_) Mechanic (_) Hair Dresser (_) Un-employed
7. Spouse's Name: __________________________
8. Relationship with spouse:
(_) Sister (_) Brother (_) Aunt (_) Uncle (_) Cousin (_) Mother (_) Father (_) Son (_) Daughter (_) Pet
9. Number of children living in household: ___
10. Number that are yours: ___
11. Mother's Name: _______________________
12. Father's Name: _______________________ (If not sure, leave blank)
13. Education: 1 2 3 4 (Circle highest grade completed)
14. Do you (_)own or (_)rent your mobile home? (Check appropriate box)
15. ___ Total number of vehicles you own
16. ___ Number of vehicles that still crank
17. ___ Number of vehicles in front yard
18. ___ Number of vehicles in back yard
19. ___ Number of vehicles on cement blocks
20. Firearms you own and where you keep them:
a. ____ truck b. ____ bedroom c. ____ bathroom d. ____ kitchen e. ____ shed
21. Model and year of your pickup: _____________ 194_
22. Do you have a gun rack? (_) Yes (_) No; If no, please explain:
23. Newspapers/magazines you subscribe to:
(_) The National Enquirer (_) The Globe (_) TV Guide (_) Soap Opera Digest (_) Rifle and Shotgun
24. ___ Number of times you've seen a UFO
25. ___ Number of times you've seen Elvis
26. ___ Number of times you've seen Elvis in a UFO
27. How often do you bathe:
(_)Weekly (_)Monthly (_)Not Applicable
28. Color of teeth:
(_)Yellow (_)Brownish-Yellow (_)Brown (_)Black (_)N/A
29. Brand of chewing tobacco you prefer:
(_)Red-Man
30. How far is your home from a paved road?
(_)1 mile (_)2 miles (_)don't know