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-Ann
Age: ____ (if unsure, guess)
Sex: ____ M _____ F _____ Not sure
Occupation (check appropriate box):
[_] 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 with spouse (please check one or more of the following):
[_] Sister [_] Aunt
[_] Brother [_] Uncle
[_] Mother [_] Son
[_] Father [_] Daughter
[_] Cousin [_] Pet
Number of children living in household: ___
Number of children living in shed: ___
Number of children that are yours: ___
Education level: 1 2 3 4 (Circle highest grade completed)
Do you [_] own or [_] rent your mobile home?
Do you have a gun rack?
[_] Yes [_] No; If no, please explain:
___ 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? (check the appropriate box):
[_] Weekly
[_] Monthly
[_] Not Applicable
How many teeth do you have? ___
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