The Retropoet

Last name:  _______________________________________

First name: (Check appropriate box)
[] Billy-Bob       [] Bobby-Sue
[] Billy-Joe       [] Bobby-Jo
[] Billy-Ray       [] Bobby-Ann
[] Billy-Sue       [] Bobby-Lee
[] Billy-Mae       [] Bobby-Ellen
[] Billy-Jack      [] Bobby-Beth Ann Sue
[] Billy-Roscoe

Age:  _______  (if unsure, guess)
Sex:  ___ M  ___ F  ___ Not sure
Shoe Size:  ____ Right ____ Left
Occupation:
[] Farmer         [] Mechanic
[] Hair Dresser   [] Waitress
[] Unemployed     [] Dirty Politician
Spouse's Name:  ____________________
2nd Spouse's Name:  ____________________
3rd Spouse's Name:  ____________________
Lover's Name:  ______________________
2nd Lover's Name:  _______________________
Relationship with spouse:
[] Sister          [] Aunt
[] Brother         [] Uncle
[] Mother          [] Son
[] Father          [] Daughter
[] Cousin          [] Pet
Number of children living in household:  ________
Number of children living in shed:  ________
Number of children that are yours:  ________
Mother's Name:  _____________________
Father's Name:  _____________________ (If not sure, leave blank)
Education: 1  2  3  4  (Circle highest grade completed)
Do you []own or []rent your mobile home? (Check appropriate box)
Vehicles you own and where you keep them:
_____  Total number of vehicles you own
_____  Number of vehicles that still crank
_____  Number of vehicles in front yard
_____  Number of vehicles in back yard
_____  Number of vehicles on cement blocks
Firearms you own and where you keep them:
_____ Truck        _____ Kitchen
_____ Bedroom      _____ Bathroom
_____ Shed
Model and year of your pickup:  __________ 194_
Do you have a gun rack?
[] Yes  []No; If no, please explain.
Newspapers/Magazines you subscribe to:
[] The National Enquirer   [] The Globe
[] TV Guide                [] Soap Opera Digest
[] Rifle and Shotgun
_____ Number of times you've seen a UFO
_____ Number of times you've seen Elvis
_____ Number of times you've seen Elvis in a UFO
How often do you bathe:
[] Weekly
[] Monthly
[] Not applicable
How many teeth?  _____
Colour of teeth:
[] Yellow  [] Brownish-Yellow
[] Brown   [] Black
[] N/A
Brand of chewing tobacco you prefer:
[] Red-Man
How far is your home from a paved road?
[] 1 mile
[] 2 miles
[] don't know

 

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