Name: ________________

                        (_) Billy-Bob

                        (_) 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

    (_)Skoal



 How far is your home from a paved road?

    (_)1 mile

    (_)2 miles

    (_)don't know