Name:__________ Nickname: Bubba____ Skeeter____ Other____
Can you sign and spell your name correctly? Sometimes____ Never____
Current Address:_____________ Number of months behind on rent:____
Neck Shade: Light Red___ Medium Red___ Dark Red___ Peeling___
Number of teeth in full grin: 1 ___ 2 ___ 3 ___ More? ___
Approximate size and weight of beer belly:______ Brand of beer:_____
Brand of chewing tobacco:______ Brand of snuff:______
Make of pick-up truck:_______ Size of tires:______ 4 Wheel Drive?___
Number of months behind in payments:_________ Does it have doors?___
Altitude of running boards: 3'___ 6'___ 12'___ 16'___
Number of empty beer cans under the seats:_____ Broken windows?____
Is truck appropiately equipped with the following?
Yes No
-- 8 track Hank Williams tapes: ___ ___
-- Pit Bull ___ ___
-- Air horns ___ ___
-- Roll bar ___ ___
-- Steer horns on hood ___ ___
-- Musical horn that plays "Dixie" ___ ___
-- "David Duke For President" bumber sticker ___ ___
-- "BOCEPHUS" bumper sticker ___ ___
-- Red Man chewing tobacco bumper sticker ___ ___
-- I love grits bumper sticker ___ ___
-- "AMERICA, LOVE IT OR LEAVE IT" bumper sticker ___ ___
-- Desert Storm bumper sticker ___ ___
-- 12 foot CB antenna ___ ___
-- Illegaly altered 1 gigawatt CB transmitter ___ ___
-- Spitoon ___ ___
-- Mud Flaps ___ ___
-- Curb Feelers ___ ___
-- Shot Guns in back window ___ ___
How many of the following items are in your front yard: (working or not)
Yes No
-- Gardens made of old tires ___ ___
-- Trucks or cars ___ ___
-- Chickens or goats ___ ___
-- Household appliances ___ ___
-- Old trailers ___ ___
-- Bath tubs ___ ___
-- TV sets ___ ___
Describe your last Elvis sighting: ______________________________________
Did you think the movie "Deliverance" was a comedy? ___________
Have you ever taken a date to a tractor pull? ____ Hog calling contest? ___
Do you own any of the following? Fertilizer hat?____ Feed Hat?____
Shoes?____ Belt buckles that weigh more than three pounds? _____ If so:
Have you worn them to Funerals___ Weddings___ Church___ Job interviews ___
Fancy restaurants like Denny's____
Do you bathe with: Soap___ Relatives___ Small animals___
How often: Weekly___ Monthly___ Twice a year___ Once a year___
Have you ever been shot at by: Ay-rabs___ Gooks___ Angry husbands___
Wives___ Fathers-in-law___ Mothers-in-law___ The Law___
Does your wife weigh more or less than: Your guitar___ Your truck___
Have you seen her in the past: Two weeks___ Two months___ Two years
Have you ever seen her when she wasn't: Pregnant___ Barefoot___ Mad___
Have you ever stayed sober for a whole weekend?_________
Can you count to 11 with your shoes on?_____ 21 with your pants on?_____
If you have had someone read all the above questions to you and you have
completely understood them then place you "X" on the line below.
>->->->->________________
_________________________
Witness signature
Contributed by: Matt Freeman