____            ____
                       \   |__________|   /
                        >  |          |  <
                       /___| KENTUCKY |___\
                           |__________|
 

 Name_____________________________________________________________
 Address_________________________________ CB Handle_______________
 Address (R.R.#)__________________________________________________
 Daddy's Name (If unknown, attach list of 3 suspects)_____________
      ____________________________________________________________
 
 Neck Shade: ( )Light Red  ( )Medium Red  ( )Dark Red  ( )Other
 Number of teeth exposed in a full grin:  ___Upper  ___Lower
 Make of Pickup: _________________  Size of Tires: _______________
 Hounds ( )Blue Tick  ( )Beagle  ( )Black&Tan  ( )Other
 Number of cars in front yard__  What makes_______________________ 
      How many on blocks__________
 Number of kitchen appliances on front porch:___ On back porch:___
 When and where was your last ELVIS sighting?_____________________
      ____________________________________________________________
 Do you wear mostly polyester pants?  ( )Yes  ( )No
      With snags? ( )Yes  ( )No
 Do you own any shoes (not boots)?  ( )Yes  ( )No
 Are you married to any of the following?  Circle ALL that apply:
      Sister  Cousin  Cousin's Sister  Aunt  Brother  
      Cousin's Brother Uncle  Other(Explain)______________________
 Does your wife weigh more than your pickup truck?________________
 Can you sign your name and always spell it right? ( )Yes ( )No
 Have you ever had more than one bath in a week? ( )Yes ( )No
 
 MEDICAL INFORMATION
 
 Do you have at least two (2) of the following?  Circle all that
      apply:
      B.O.  Crabs  Lice  Bad Breath  Scabies  Fleas  Tatoos  
      Crossed Eyes  Runny Nose  Green Teeth  Yellow Teeth  
      Any Teeth?  Number of teeth missing:________________________
 
 GENERAL INFORMATION
 
 Can you count to 10 with your shoes ON?  ( )Yes  ( )No
 Can you count to 21 with your fly zipped?  ( )Yes  ( )No
 Favorite weapon?  Circle all that apply:
      Tire Iron  Pick Handle  Log Chain  Shotgun
 Favorite Pasttime? ( )Drinkin' ( )Coon Huntin' ( )Fishin'
      Other_______________________________________________________
 Truck equipped with: ( )Gunrack ( )Fuzzbuster ( )8-track
      ( )Rebel Flag ( )Roll Bar ( )CBRadio ( )Beer Cans 
      ( )Squirrel Tail
 Favorite vocalist: ( )Willie Nelson ( )Johnny Cash ( )Elvis 
      ( )Conway Twitty
 Bumper Stickers: ( )Honk if you love Jesus ( )Dial 1-800-Eat-Shit
      ( )Old Fart
 Cap Emblems: ( )John Deere ( )CAT ( )Skoal ( )Budweiser 
      ( )Jack Daniels
 Memberships: ( )NRA ( )VFW ( )KKK ( )700 Club ( )B.P.O.E.

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amethyst@endor.org - 1995