Name: ________________  (_) Billy-Bob
               (last)        (_) Billy-Joe
                             (_) Billy-Ray
                             (_) Billy-Sue
                             (_) Billy-Mae
                             (_) Billy-Jack
                             (Check appropriate box)

      Age: ____
      Sex: ____ M _____ F _____ N/A
      Shoe Size ____ Left ____ Right

      Occupation:
      (_) Farmer
      (_) Mechanic
      (_) Hair Dresser
      (_) Un-employed

      Spouse's Name: __________________________

      Relationship with spouse:
      (_) Sister
      (_) Brother
      (_) Aunt
      (_) Uncle
      (_) Cousin
      (_) Mother
      (_) Father
      (_) Son
      (_) Daughter
      (_) Pet

      Number of children living in household: ___

      Number 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)

      ___ 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
      ____ bedroom
      ____ bathroom
      ____ kitchen
      ____ shed

      Model and year of your pickup: _____________ 194_

      Do you have a gun rack?
      (_) Yes (_) No; please explain:



      Newspapers/magazines you subscribe to:
      (_) The National Enquirer
      (_) The Globe
      (_) TV Guide
      (_) Soap Opera Digest
      (_) Rifle and Shotgun

      ___ 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

      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
      (_)don't know