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?

 ___ 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