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Name:______________ Nickname:____________ CB Handle:____________
Address: (RFD):_________________________________________________
Daddy: (If unknown attach list of three 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 [] 4-Wheel Drive [] Confederate Flag [] Toothpick Holder [] 8-Track [] Load of Wood [] Hijacker Shocks [] Mud-grip Tires [] Big Dog [] Racoon Hide [] Dual CB Antenna [] Fuzz Buster [] Spitoon [] Camper Top [] Mag Wheels [] Air Horns [] Mud Flaps
Number of Empty Beer Cans on Floor Board of Pickup:_________
Bumper Stickers: [] Eat More Possum [] Peanut Butter [] Honk if You Love Jesus [] Wave if You're Horny [] Redman Chewing Tobacco
Define the following (Must be 90% correct): [] Grits [] Muscadine [] Cobbler [] Tater [] Goobers [] Brogans [] Fatback [] Pig Skins [] Collards [] Redeye Gravy [] Tote [] Pinto Beans [] Sidemeat [] Sawmill Gravy [] Poke [] Turnip Salit [] Chitlins [] Soppin Syrup [] Cracker [] Shit-on-Shingle [] Ramps
Favorite Vocalist: [] Donna Fargo [] Conway Twitty [] Loretta Lynn [] Hank Williams [] Elvis [] Slim Whitman [] Tammy Wynette [] Porter Wagoner [] Johnny Cash [] Willie Nelson [] George Jones [] Box Car Willie
Favorite Recreation: [] Square Dancin' [] Possum Huntin' [] Skinny Dippin' [] Craw Daddin' [] Gospel Singin' [] 4-Wheelin' [] Drankin' [] Bull Chip Throwin' [] Blue Grass Conventions [] Spitten' backy [] Other
Weapons Owned: [] Deer Rifle [] Bird Gun [] Varmit Rifle [] Sawed-off Shotgun [] Tire Iron [] Pick Handle [] Log Chain [] Power (chain) saw
Number of Hound Dogs:___ Type: [] Blue Tick [] Black & Tan [] Beagle
Emblem: [] John Deere [] CAT [] Budweiser [] McCullock Chain Saw [] PBR [] NAPA [] Coors [] Skoals
Number of Weeks Unemployed:_____ Number of Welfare Checks Received:_____
Number of Dependents (Legal):______ (Claimed):______
Memberships: [] KKK [] NRA [] Moose [] PTL Club [] VFW [] American Legion [] Bass Club [] United Sons/Daughters of the Confederacy
Length of Left Leg:______ Length of Right Leg:______
Does your truck contain some part painted the official state color, Primer Red?______
How many cars do you have jacked up on blocks in your front yard?______
How many kitchen appliances (working or not) will you keep on your front porch?______
Will you be a part of the West Virginia Intelligentsia with a measurable IQ?______
Do you wear mostly double knit polyester pants with snags?______
Do you own any shoes, if so 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?______
Can you count: Past 10 with your shoes on? ______ To 21 with your fly up? ______
Medical Information: Do you have at least 2 of the following: [] BO [] Crabs [] Head Lice [] Bad Breath [] Scabies [] Trench Mouth [] Runny Nose
Do you know any words that have more than 4 letters?______
Have you EVER had more than one bath in a week? ______
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