Name:__________________________
Nickname:________________________________

CB Handle:_____________________

Address (RFD No.):_________________--____________________________________

Daddy (If unknown, list 3 suspects):_____________________________________

Mamma:_________________________

Neck Shade (check one):
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
____Cassette Deck
____Load of Wood
____Hijacker Shocks
____Radar Detector
____Mag Wheels
____Dual CB Antennas
____Spittoon
____Camper Top
____Air Horns
____Mud Flaps
____Toothpick Holder
____Mud-Grip Tires
____Raccoon Hide
____Big Dog
____Spotlight

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
____Redman Chewing Tobacco
____If you ain't a cowboy you aint shit

Define the following (must be 90% correct):
1. Grits
2. Goobers
3. Pinto Beans
4. Collards
5. Sidemeat
6. Sawmill Gravy
7. Turnip Salad
8. Shit-on-a-Shingle
9. Redeye Gravy
10. Soppin' Syrup
11. Cobbler
12. Fatback
13. Tote
14. Chickin' Fry
15. Poke
16. Tater
17. Pig Skins
18. Okrie
19. Shonuf
20. Chitlins

Favorite Vocalist:
____Reba McEntire
____Conway Twitty
____Loretta Lynn
____Hank Williams
____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'
____4-Wheelin'
____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
___Sawed-Off 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
___Vo-Tech
___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:
___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 official 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 double-knit 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

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
___Trench Mouth
___Runny Nose
___Bad Breath

IF YOUR APPLICATION IS TURNED DOWN BY THE SOUTH YOU MAY BE ELIGIBLE IN THE NORTH. THEIR STANDARDS ARE SLIGHTLY LOWER. HOWEVER, YOU WOULD STILL BE ABLE TO VISIT PARTS OF THE SOUTH.