Maineiac

NAME: ___________________________________  C.B. HANDLE: ____________________

ADDRESS: (R.F.D. - H.C.R.) _________________________________________________


DADDY (If unknown, attach list of 3 suspects): _____________________________


MAMA: ______________________________________________________________________


NECK SHADE:  ( ) LIGHT RED    ( ) MEDIUM RED    ( ) DARK RED

NUMBER OF TEETH EXPOSED IN FULL GRIN: _______  UPPER: _______ LOWER: _______


MAKE OF PICKUP OWNED: _____________________  SIZE OF TIRES: ________________


NUMBER OF EMPTY BEER CANS ON FLOOR OF PICKUP: ______________________________


TRUCK EQUIPPED WITH:

( ) GUN RACK       ( ) MUD FLAPS         ( ) CAMPER TOP        ( ) AIR HORN
( ) 8 TRACK        ( ) 4 WHEEL DRIVE     ( ) AMERICAN FLAG     ( ) RUST
( ) FUZZ BUSTER    ( ) LOAD OF WOOD      ( ) HIJACK SHOCKS     ( ) MUD TIRES
( ) SPITTOON       ( ) RUNNING BOARDS    ( ) C.B. ANTENNAS     ( ) ROLL BAR


BUMPER STICKERS:

( ) HONK IF YOU LOVE JESUS
( ) ALMOST HEAVEN, BUCKSPORT
( ) REDMAN CHEWING TOBACCO
( ) WOOD IS WONDERFUL 
( ) SAVE THE BLACK FLY
( ) DON'T LIKE MY DRIVING?  CALL 1-800-*&^-#$@!
( ) ALL YOU ECOLOGICAL DUMMIES CAN FREEZE IN THE DARK


FAVORITE BEVERAGE:

( ) BUSCH       ( ) STAG                ( ) OLD STYLE     ( ) FALSTAFF
( ) BUCKHORN    ( ) RED WHITE & BLUE    ( ) BUDWEISER     ( ) OLD MILWAUKEE

FAVORITE VOCALIST:

( ) ELVIS                ( ) CONWAY TWITTY        ( ) LORETTA LYNN
( ) SLIM WHITMAN         ( ) JOHNNY CASH          ( ) WILLIE NELSON
( ) DICK CURTIS          ( ) GEORGE JONES         ( ) YOURSELF IN THE SHOWER

FAVORITE RECREATION:

( ) SQUARE DANCING         ( ) COON HUNTING        ( ) FISHING WITH THE BOYS
( ) DRINKING               ( ) BLUE GRASS FEST     ( ) FISHING ALONE
( ) RACE TRACK             ( ) FLOATING            ( ) DEER HUNTING
( ) APPLE BUTTER FEST      ( ) THREE WHEELING      ( ) RODEO

HOW MANY CARS DO YOU HAVE UP ON BLOCKS IN YOUR FRONT YARD? _________________

HOW MANY KITCHEN APPLIANCES ARE ON YOUR FRONT PORCH? ____  HOW MANY WORK? __

NUMBER OF HOUNDS: _________ TYPE: ( ) BLUE TICK   ( ) BEAGLE   ( ) BLACK/TAN

MEMBERSHIPS:

( ) NRA                ( ) VFW    ( ) PTL CLUB           ( ) DUCKS UNLIMITED
( ) FISH & GAME CLUB   ( ) KKK    ( ) WACKY WARRIORS     ( ) ELKS

BASEBALL CAP EMBLEM:

( ) JOHN DEERE            ( ) FORD           ( ) SKOAL            ( ) CAT
( ) BUDWEISER             ( ) CHEVY          ( ) BASS PRO         

ARE YOU MARRIED TO ANY OF THE FOLLOWING?  (Check all that apply)

( ) SISTER            ( ) COUSIN         ( ) COUSIN'S SISTER         ( ) SOW

DOES YOUR WIFE WEIGH MORE THAN YOUR PICKUP?                 ( ) YES  ( ) NO

DO YOU WEAR MOSTLY POLYESTER PANTS WITH SNAGS?               ( ) YES  ( ) NO

DO YOU OWN ANY SHOES (NOT COUNTING BOOTS)?  IF SO, HOW MANY? ______________

LENGTH OF RIGHT LEG: _________________ LENGTH OF LEFT LEG: _________________

CAN YOU SIGN YOUR NAME AND SPELL IT CORRECTLY EVERY TIME?    ( ) YES  ( ) NO

HAVE YOU EVER HAD MORE THAN ONE BATH A WEEK?                 ( ) YES  ( ) NO

ARE YOU A REGISTERED VOTER?  ________  DO YOU KNOW WHERE TO DO IT? ________

DO YOU WONDER IF YOU NEED TO FILE A TAX RETURN?              ( ) YES  ( ) NO

DO YOU WORRY THAT YOUR HOUSE COULD BLOW AWAY IN HIGH WINDS?  ( ) YES  ( ) NO

WHEN WAS YOUR LAST UFO SIGHTING?  ___________   ELVIS SIGHTING? ___________

MEDICAL INFORMATION (DO YOU HAVE AT LEAST TWO OF THE FOLLOWING?):

( ) B.O.           ( ) HEAD LICE        ( ) BAD BREATH
( ) SCABIES        ( ) YELLOW TEETH      ( ) GREEN TEETH      ( ) FLEAS
( ) RUNNY NOSE     ( ) TATTOOS           ( ) CROSSED EYES     ( ) STUTTER



SIGNATURE (ONE `X' WILL DO)  ___________________________ DATED: ____________