Personal Information:
Name__________ Nickname__________ CB Handle_________
Yore Mama______________ Yore Daddy (if known)__________
Spouse's Name_________________ Relationship to spouse:
___Sister ____Brother ____Mother ____Father___Pet ___Aunt = ___Uncle

Occupation: ___Unemployed Mechanic ___Gun Show Dealer___Skinhead

Number of Children in Household___ Number that are yours___

Circle Highest Level of Education: 1 2 3 4

How Far is Your Mobile Home From a Paved Road: ___1mi. __5 mi. ___?

Number of Times You Have Survived a Tornado: ___

Number of Vehicles Owned___

Number on Cement Blocks___

Truck Equipment: ___Gun Rack ___Pit Bull___Spit Cup ___Fuzzy Dice ___Rebel Flag ___Naked Woman Mudflaps___NWO and/or NRA sticker

Weapons Owned:
___Tire Iron ___Pick Handle___Beer Bottle___Shotgun

Number of Dogs Owned: ___

Number of Homemade Tattoos: ___

Which of the Following Appliances are in your Front Yard:
___Friggerator ___Heatin Stove ___Warsher ___TV ___Freezer

How Many of the Above Appliances Work: ___

Fav-o-rite Recreation: ___Drinkin ___Cow Chip Throwin ___Possum Huntin___Crawdad Huntin ___Spittin ___Backy Scratchin ___ Watchin=20 Wrasslin

If You Can Read, Which Magazines Do You Prefer:
___Soap Opera Digest___Rifle and Shotgun ___NWA ___TV Guide ___National Enquirer ___True Confessions

Which Stinks Worse: ___Hogpen ___Outhouse___Spouse

Have You Ever Stayed Sober for More Than One Day: ___Yup___Nope

Do You Know Any Words with More Than 4 Letters: ___Yup ___Nope

Which is Correct?: ___"I Seed Him" or ___"I Seen Him"

How Many Cartons of Cigarettes Do You Smoke a Day? ___

Math Test: How Many Food Stamps Do the Following Cost?
___Six Pack ___Ciggies ___Shotgun Shells ___Backy___Prostitute

Number of Times You've Seen: ___a UFO ___Elvis ___Elvis in a UFO

Health Questionaire: Which of the Following Do You Have?
___Head Lice ___B.O. ___Crabs ___Runny Nose ___Boils

Can You Remember the Last Time You Bathed? ___Yup ___Nope

Color of Teeth: ___Yellow ___Brown___Black ___N/A

I hereby swear this is the trooth and sign my "X" on __________________, 2001

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