Name: __________________________  Nickname: _____________________________

CB Handle Model:_____________________  Color:______________

Address (RFD No.):_________________--_________________________________

Daddy (If unknown, list 3 suspects): __________________________________

Mamma:_________________________

Neck Shade:     _____Light Red       _____Medium Red       _____Dark Red

Number of teeth exposed in full grin:       Upper_____     Lower_____

Name of Pickup owned:_______________ Height of Truck__________

Truck equipped with:
 ____Gun Rack            ____4-Wheel Drive       ____Confederate Flag
 ____8-Track Cassettes   ____Load of Wood        ____Hijacker Shocks
 ____Radar Detector      ____Mag Wheels          ____Dual CB Antennas
 ____Spittoon            ____Camper Top          ____Air Horns
 ____Mud Flaps           ____Toothpick Holder    ____Mud-Grip Tires
 ____Raccoon Hide        ____Big Dog             ____Hunting Rifle

Number of empty beer cans on floorboard or in bed of pickup truck:____

BUMPER STICKERS:
 ____Eat more Possum             ____My other car is a piece of shit too
 ____Honk if you love Jesus      ____If you ain't a cowboy you aint shit
 ____Redman Chewing Tobacco      ____Wave if you're horny
 ____I Brake For Nuthin'         ____National Rifle Association
 ____Don't Like My Driving? Dial 1-800-Eat-Shit
 ____If You Can Read This, Then You's Too Smart For Kentucky

Define the following (must be 90% correct):
 1. Grits        6. Sawmill Gravy        11. Cobbler     16. Tater
 2. Goobers      7. Turnip Salad         12. Fatback     17. Pig Skins
 3. Pinto Beans  8. Shit-on-a-Shingle    13. Tote        18. Okrie
 4. Collards     9. Redeye Gravy         14. Chickin'Fry 19. Shonuf
 5. Sidemeat     10. Soppin' Syrup       15. Poke        20. Chitlins

Favorite Vocalist:
 ____Reba McEntire       ____Conway Twitty       ____Loretta Lynn
 ____Hank Williams Jr.   ____Randy Travis        ____Ray Wylie Hubbard
 ____Tammy Wynette       ____Slim Whitman        ____Porter Wagoner
 ____Willie Nelson       ____George Jones        ____Box Car Willie

Favorite Recreation:
 ____Square Dancin'      ____Possum Huntin'      ____Skinny Dippin'
 ____Craw Daddin'        ____Gospel Singin'      ____4-Wheelin'
 ____Drankin'            ____Spittin' Backy      ____Bill Chip Throwin'
 ____Honky Tonkin'       ____Noodlin'            ____Other

Name of Son(s):   ____Bubba   ____Jim Bob    ____LeeRoy   ____J.D.
                  ____Bill Lee____Bob Lee    ____Duke

Name of Daughter(s):  ____PammySue   ____Violet   ____Paulette   ____Daisy

Weapons Owned:
 ___Deer Rifle   ___Sawed-Off Shotgun    ___Varmit Rifle ___Log Cabin
 ___Tire Iron    ___Power Chain Saw      ___Pick Handle  ___Hick'ry Swich

Number of Dogs:____    Type:    ___Blue Tick    ___Beagle
                                ___Black & Tan  ___Bird Dawg

Cap Emblem:     ___John Deere   ___McCullock Chain Saws    ___Budweiser
                ___Vo-Tech      ___Skoal                   ___Coors
                ___NAPA         ___Redman                  ___Kodiak         
                ___N.R.A.       ___Smile if You're Not Wearing Underwear

Number of Dependends:    Legal:________         Claimed:_________

Number of Weeks Unemployed:__________

Number of Welfare Checks Received:____________

Memberships:
 ___KKK          ___NRA          ___Moose        ___PTL Club        ___AAA
 ___Bass Club    ___VFW          ___Quiltin' Bee ___American Legion
 ___United Sons/Daughters of the Confederacy
 ___John Birch Society

Length of Right leg:________            Length of Left leg:__________

Number of Testicles Shot off in 'Nam____  Number of Testicles Left____

Does your truck contain some part painted the offical state color of
 Primer Red?  ___Yes    ___No

How many cars do you have jacked up on blocks in your front yard?_____

How many kitchen appliances will you keep on your front porch?_______

Will you wear mostly double-knit polyester pants with snags?__________

Do you own any shoes?   ____Yes    ____No    If yes, how many?________

What year did you last purchase shoes?_________________

Are you married to any of the following:
  ____Sister      ____Cousin      ____Sow

Do you know her name?________________

Does your wife weigh more than your pickup?____________

Can you sign your name and get the spelling right every time?_________

Have you ever stayed sober for a whole weekend?________________
 If so, why?___________________________________________________________

Can you count:  Past 10 with your shoes on?_________________
                To 21 with your fly up?_____________________

Do you know any words that have more than four letters?_______________

Have you ever had more than one bath in a week?_______________________

Medical Information:
 Do you have at least two of the following:
  ___BO           ___Crabs        ___Head Lice    ___Rabies
  ___Trench Mouth ___Runny Nose   ___Bad Breath   ___Chafing

     If your application is turned down by the state of Kentucky, you may
be eligible in the states of Texas, Oklahoma, Tennessee, or Arkansas.
Their standards are slightly lower, however, you will still be able to
visit Kentucky.