Last name 

        First name (Check appropriate box)

        Billy-Bob           Bobby-Sue

        Billy-Joe            Bobby-Jo

        Billy-Ray            Bobby-Ann

        Billy-Sue            Bobby-Lee

        Billy-Mae           Bobby-Ellen

        Billy-Jack          Bobby-Beth

        Age (if unsure, guess)

        Sex M F    Not sure

        Shoe Size       Left Right

        Occupation

        Farmer                   Mechanic

        Hair Dresser           Waitress

        Unemployed           Dirty Politician

        Spouse's Name

        2nd Spouse's Name

        3rd Spouse's Name

        Lover's Name

        2nd Lover's Name

        Relationship to spouse:

        Sister            Aunt

        Brother          Uncle

        Mother            Son

        Father           Daughter

        Cousin            Pet

        Number of children living in household

        Number of children living in shed

        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
 

               Where you keep them firearms

                  truck             kitchen

                  bedroom     bathroom

                  shed

                  Model and year of your pickup 194

                  Do you have a gun rack?

                  Yes No; If no, please explain
 

                 Newspapers/magazines you subscribe to

                The National Enquirer      [_] The Globe

                TV Guide                        Soap Opera Digest

                Rifle and Shotgun           Guns And Ammo
 

                  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                Teeth?

                Brand of chewing tobacco you prefer

                   Red-Man       Shoal

                How far is your home from a paved road?

                   1 mile                    2 miles                    don't know

  Lastly,.. who is your insurance provider

                        Colt 45mm   38 Special   Smith & Wesson
                        Grandpa's olde 30-30 shotgun   Other