Last name: ________________

First name (check appropriate box):

Sex: ____ M _____ F _____ Not sure

Shoe Size: ____ Left ____ Right

Occupation:

Relationship with spouse:

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?

Vehicles you own and where you keep them:

Firearms you own and where you keep them:


Model of your pickup: _____________
Year pickup produced: 194____


Do you have a gun rack?
___ 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:
Brand of chewing tobacco you prefer: