Name:______________________ Nickname:______________________

CB Handle:_________________________________________________

Current Address:_____________________________________________

Neck Shade: ( ) Light Red ( ) Medium Red ( ) Dark Red

Number of teeth exposed in full grin:_____ Upper:_______ Lower:_______

Number of teeth missing in a full grin:_____ Upper:_______ Lower:_______

Make of pickup:_______________________ Size of tires:____________

Does it have doors?: ( ) Yes ( ) No ( ) Sometimes ( ) Can't remember

How high is the first step into your pickup?: ( ) 3 feet ( ) 6 feet ( ) More

Number of empty beer cans on the floor of pickup:____________________

Number of empty peanut shells on floor of pickup:_____________________

Truck equipped with:
( ) Rust ( ) Gun rack ( ) camper top ( ) Hi-jack shocks
( ) Winch ( ) Roll bar ( ) Rottweiler ( ) Running Boards
( ) 8 Track ( ) Spittoon ( ) Fuzz Buster ( ) Load of compost
( ) Pit bull ( ) Mud Tires ( ) Curb feelers ( ) 4-wheel drive
( ) Air horn ( ) Mud flaps ( ) Confederate flag ( )A fat bitch
( ) Bullet holes ( )Mis-matched tires

Bumper sticker:

( ) I Love Grits ( )Redman Chewing Tobacco ( ) Eat Mo' Possum
( ) Jesse Helms For President ( ) I Dig Boiled Peanuts
( ) Honk If You Love Jesus

Length of right leg:______________ Left leg:______________

How many cars do you have on blocks in your front yard?:______________

When was your last Elvis sighting?:_______________________________

How many appliances do you keep on your front lawn?:________________

Working Appliances:_________ Non-working Appliances:_____________

Do you own any shoes (not boots)? ( ) Yes ( ) No

If so, How many?:_____________

Do you bathe?: ( ) Weekly ( ) Monthly ( ) Bi-yearly ( ) With soap

Are you married to either of the following?: ( ) Sister ( ) Cousin ( ) Mother

Does your wife weigh more than your pickup?: ( ) Yes ( ) No

How long has it been since you worked?: ( ) 3 years ( ) More than 3 years ( ) Never

How many cases of Coors do you drink every night?:
( ) two cases ( ) more than 2 cases ( ) Can't count

Can you sign your name and spell it right every time? ( ) yes ( ) No

Can you read?: ( ) Yes ( ) No