First name:___________________Last name(if known):_______________________
Address (where you live):______________________________________
Mother's name(list also relation, i.e., sister):__________________ 
Birthdate(yours):____________________
Father's name (if known, if not, list two possible choices)______________
Color of neck: Light Red( ) Medium Red( ) Dark Red( ) No Neck( )
Year of pickup truck:____________ Do you have the following in your truck:
				  Fuzzy Dice( )  Gun Rack( )  Coon Tail( )
				  Filled ash tray( )  Used Condoms( )
				  Dead Road Kill( ) Dog of Unknown Breed( )
Have you ever been to a large city? (Like Little Rock) Yes( ) No( )
How far can you throw cow pies?__________ Do you eat cow pies? Yes( ) No( )
Wife's name:__________________ Is she: Cousin( ) Neighbor( ) Sister( )
				       Mother( ) Neighbor's dog( ) 
				       Right hand( )
Does your wife weigh: Less than 200 Pounds( ) Less than 300 Pounds( )
		      Less than a 747( ) More than a 747( )
Do you know what a 747 is? Yes( ) No( )
How much smarter than you is your wife:
		50 IQ Points( )   75 IQ Points( )
		100 IQ Points( )  She Won't Tell Me( )
Does your wife wear:
		A Dress( )     Pants( )   Hot Pants( )  
		Your Pants( )  Them Lawyer Clothes( )
		Nothing( )     Nothing but an Arkansas U Hog Head Hat( )
Did you understand the previous questions:
		Yes( )   No( )   What does "previous" mean?( )   
		Huh?( )  All of the Above( )
Color of wife's hair:  Blonde( )  Red( )  Brown( )  Black( )  Bald( )
Have you ever had: Herpes( ) Jock Rot( ) The Drip( ) Roids( ) Zits( )
(Check all that    Smelly Feet( ) Toe Jam( ) Bad Breath( ) Tit Munge( )
 apply)            Ear Wax( ) Long Nasal Hairs( ) Brown Nose( )
Have you ever: Castrated a Pig( )  Been Castrated by a Pig( ) 
	       Danced to Achey Breaky Heart( ) Had an Achey Breaky Heart( )
	       Been Mistaken for Elvis( ) Had Fantasies about Toto( )
	       Had Fantasies about Dorothy and Toto( )  
	       Had Fantasies about Gilligan( )
	       Had Fantasies about Gilligan and the Skipper Too( )
	       Inhaled( )
Where was your last Elvis sighting?________________ On what date?___________
Can you count past five: Yes( ) No( )  Past ten: Yes( ) No( )
Explain in ten words or less why on Earth you want to be Governor of Arkansas:
___________________________________________________________________________

Signature (or 'X' if you can't write)________________________________