Please fill in the following:

Name:___________________________________________________________

Nickname:___________________________

CB Handle:___________________

Address (RFD):____________________________________________________

Daddy (if unknown affix list of 3 suspects):_______________________________

Neck size:____

( ) Light Red

( ) Medium Red

( ) Dark Red

( ) Other

Number of teeth exposed in full grin:____Upper:_____ Lower:____

Make of Pickup:_________________________

Tire Size:______________

Hounds:_____________

Type:

( ) Blue Tick

( ) Beagle

( ) Black and Tan

Length of right leg:__________

Length of left leg:__________

other:_________

How many cars/makes in front yard? ______________________________

How many on blocks? _____________________________________________

How many kitchen appliances on front porch? ___________________

Back porch?___________

When and where was your last "Elvis" sighting? _______________________________________

Do you wear mostly polyester pants with snags?

( ) Yes ( ) No

Are you married to any of the following?(circle all that apply)

-Sister

-Cousin

-Cousin's Sister

-Other, Explain:_________________________________________________

Have you EVER had more than one bath a week?

( ) No ( ) Yes, Explain:_________________________________________

Medical Information

Do you have at least two (2) of the following:

( ) B.O.

( ) Lice

( ) Crabs

( ) Bad Breath

( ) Hoof in Mouth

( ) Scabs

( ) Fleas

( ) Infected Tattoos

( ) Crossed eyes

( ) Runny Nose

( ) Green Teeth

( ) Yellow Teeth

( ) Any Teeth

( ) Speach Impediment

General Information

Can you count past 20 without stripping?

( ) yes ( ) no( ) never tried

Favorite Weapon:

( ) Tire Iron

( ) Pick Handle

( ) Log Chain

( ) Shotgun

Favorite Pastime:

( ) Drinkin'

( ) Coon Huntin'

( ) Fishin'

( ) Fuedin'

( ) Other

Truck equipped with:

( ) Gun Rack

( ) Fuzzbuster

( ) 8-Track

( ) Rebel Flag

( ) Roll Bar

( ) C.B. Radio

( ) Beer Cans

( ) Squirrel Tail

( ) Bull Horns

Favorite Vocalist:

( ) Elvis (the young Elvis)

( ) Elvis (the old Elvis)

( ) Elvis (dead)

Cap Emblems:

( ) John Deere

( ) CAT

( ) SKOAL

( ) Budweiser

( ) Bud Dry

( ) Jack Daniels

( ) Teamsters local

Memberships:

( ) NRA

( ) VFW

( ) KKK

( ) 700 Club

( ) B.P.O.E.

( ) Sine-aid Society

Do you vote?

( ) Yes( ) No( ) What's that?

Have you ever been in jail?

( ) Yes( ) No( ) Born there

Date:____________

Your Signature (one X will do): _______________________