Name:__________________________

Nickname:_________________________________

CB Handle:_____________________

Address (RFD No.):_________________ƒƒ_____________________________________

Daddy (If unknown, list 3 suspects):______________________________________

Mamma:_________________________

Neck Shade: _____Light Red _____Medium Red _____Dark Red

Number of teeth exposed in full grin: Upper_____ Lower_____

Name of Pickup owned:_______________ Height of Truck__________

Truck equipped with:

____Gun Rack ____4ƒWheel Drive ____Confederate Flag

____Cassette Deck ____Load of Wood ____Hijacker Shocks

____Radar Detector ____Mag Wheels ____Dual CB Antennas

____Spittoon ____Camper Top ____Air Horns

____Mud Flaps ____Toothpick Holder ____MudƒGrip Tires

____Raccoon Hide ____Big Dog

Number of empty beer cans on floorboard or in bed of pickup truck:_____

BUMPER STICKERS:

____Eat more Possum ____My other car is a piece of shit too

____Honk if you love Jesus ____If you ain't a cowboy you aint shit

____Redman Chewing Tobacco

Define the following (must be 90% correct):

1 Grits 6 Sawmill Gravy 11 Cobbler 16 Tater

2 Goobers 7 Turnip Salad 12 Fatback 17 Pig Skins

3 Pinto Beans 8 ShitƒonƒaƒShingle 13 Tote 18 Okrie

4 Collards 9 Redeye Gravy 14 Chickin' Fry19 Shonuf

5 Sidemeat 10 Soppin' Syrup 15 Poke 20 Chitlins

Favorite Vocalist:

____Reba McEntire ____Conway Twitty ____Loretta Lynn

____Hank Williams Jr. ____Randy Travis ____Ray Wylie Hubbard

____Tammy Wynette ____Slim Whitman ____Porter Wagoner

____Willie Nelson ____George Jones ____Box Car Willie

Favorite Recreation:

____Square Dancin' ____Possum Huntin' ____Skinny Dippin'

____Craw Daddin' ____Gospel Singin' ____4ƒWheelin'

____Drankin' ____Spittin' Backy ____Bill Chip Throwin'

____Honky Tonkin' ____Noodlin' ____Other

Name of Son(s): ____Bubba ____Jim Bob ____LeeRoy ____J.D.

Name of Daughter(s): ____PammySue ____Violet ____Paulette ____Daisy

Weapons Owned:

___Deer Rifle ___SawedƒOff Shotgun ___Varmint Rifle ___Log Cabin

___Tire Iron ___Power Chain Saw ___Pick Handle ___Hick'ry Switch

Number of Dogs:____ Type: ___Blue Tick ___Beagle

___Black & Tan ___Bird Dawg

Cap Emblem: ___John Deer ___McCullock Chain Saws ___Budweiser

___VoƒTech ___Skoal ___Coors

___NAPA ___Smile if You're Not Wearing Underwear

Number of Dependents: Legal:________ Claimed:_________

Number of Weeks Unemployed:__________

Number of Welfare Checks Received:____________

Memberships:

___KKK ___NRA ___Moose ___PTL Club ___AA

___Bass Club ___VFW ___Quiltin' Bee ___American Legion

___United Sons n' Daughters of the Confederacy

___John Birch Society

Length of Right leg:________ Length of Left leg:__________

Does your truck contain some part painted the offical state color of

Primer Red? ___Yes ___No

How many cars do you have jacked up on blocks in your front yard?_______

How many kitchen appliances will you keep on your front porch?__________

Will you wear mostly doubleƒknit polyester pants with snags?____________

Do you own any shoes? ____Yes ____No If yes, how many?__________

What year did you last purchase shoes?_________________

Are you married to any of the following:

____Sister ____Cousin ____Sow

Do you know her name?________________

Does your wife weigh more than your pickup?____________

Can you sign your name and get the spelling right every time?____________

Have you ever stayed sober for a whole weekend?________________

If so, why?________________________________________________________

Can you count: Past 10 with your shoes on?_________________

Do you know any words that have more than four letters?__________________

Have you ever had more than one bath in a week?__________________________

Medical Information:

Do you have at least two of the following:

___BO ___Head Lice ___Rabies