Name:________________
(Last)

(_) Billy Bob
(_) Billy Sam
(_) Billy John
(_) Billy Bill
(_) El Roy
(_) Lee Roy
(_) Billy Jack
(_) Billy Don
(_) Other_________
(check all that apply)

Age____
Sex: M____ F____ N/A_____ Both_____ Dont Know____
Shoe Size: Right____ Left____

Occupation:
(_)hair Dresser
(_) Farmer
(_) Machanic
(_)Homeless
(_) Unemployed

Spouses Name:_______________
Relationship with Spouse
(_) Mother
(_) Father
(_) Sister
(_) Brother
(_) Cousin
(_) Aunt
(_) Uncle
(_) Pet

Number of Children living in your house:________
Number that are yours:__________

Mothers Name_________
Fathers Name_______________
(If not sure leave blank)

Do you Own(_) or Rent(_) your moble Home
(check appropiate box)

Number of vehicles owned____
Number of Vehicles that still crank________
Number of Vehicles in Front yard_________
Number of Vehicles in Back yard_________
Number of Vehicles on cement blocks______

Number of Firearms owned
Less than 10(_)
10(_)
20(_)
30(_)
50(_)
More than 50(_)
dont know cant count past 10(_)

Where do you keep these firearms
(_)Truck
(_)Matress/bed
(_)wifes Perse
(_)Shed
(_)Kitchen
(_)Bathroom
(_)Just laying around

Model of Pickup truck________ year 197____

Nespapers/magazines that you subscribe to
(_)Weekly world News
(_)National Enquirer
(_)TV Guide
(_)Soap Opera Digest
(_)The Globe
(_)Weekly Elvis Report
(_)Cant read, someone else is filling this out
( Check all that apply)

Number of time you have seen a UFO_____
Number of time you have seen Elvis_______
Number of time you seen Elvis in a UFO____

How often do you Bathe
(_)Weekly
(_)Monthly
(_)Not Applicable

Color Of Teeth
(_)Yellow
(_)Green
(_)Black
(_)Brown
(_)Non

Brand of Chewing Tabbacco
(_)Redman
(_)Big Legue
(_)Coppenhagen
(_)Homemade

What kind of whisky do you drink
(_)Jack Daniels special
(_)Colt
(_)Crown Royal
(_)Dinoquerval special
(_)Homemade Shine
(_)Relative shine

How do you get you Whisky/Beer
(_)Store-Buy it
(_)Store-Steal it
(_)Store-friend/relitive works there gets it to you
(_)Make it at home
(_)Friend or family member makes it
(_)Steal it from friend or family member
(_)Sell you body for it
(_)Bartering(Trading one thing for Whisky)

How Far from a paved road do you live
(_)1 mile
(_)2 miles
(_)3 Miles
(_)3-10 Miles
(_)More than 10
(_)Dont Know