Personal Information:


Name________________ Nickname______________ CB Handle___________

Yore Mama Name______________ Yore Daddy Name(if known)________________

Spouse's Name_________________

Relationship to spouse: (Delete as nec.) Sister/Brother/Mother /Father/Pet/Aunt/Uncle

Occupation: (Delete as nec.) 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: (Delete as nec.)
Gun Rack/ Pit Bull/ Spit Cup/ Fuzzy Dice/ Rebel Flag/ Naked Woman Mud flaps/ NRA sticker

Weapons Owned: Tire Iron / Pick Handle / Beer Bottle / Shotgun

Number of Dogs Owned: __ Number of Homemade Tattoos: ___

Which Appliances are in your Front Yard: Friggerator /Heatin Stove /Warsher /TV /Freezer

How Many of the Above Appliances Work: ___


Fav-o-rite Recreation: (Delete as nec.)

Drinkin / Cow Chip Throwin / Possum Huntin / Spittin Backy / Scratchin / Watchin Wrasslin

If You Can Read, Which Magazines Do You Prefer: (Delete as nec.)

Soap Opera Digest / Rifle and Shotgun / NWA / TV Guide / National Enquirer / Don’t Read

Which Stinks Worse: Hogpen ___ Outhouse ___ Spouse___

Can You Spell Your Last Name: Yup ___ Nope___

Can You Remember Your Last Name: Yup ___ Nope___

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" ___ "I Seen Him"___

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 Questionnaire: 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

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