Name: ___________________________________________________________
Nickname: ______________________ CB Handle: ____________________
Address (RFD No.): _____________________________________________
Daddy (If Unknown, attach list of three suspects): _____________
Mama: __________________________________________________________
Neck Shade: * Light Red * Medium Red * Dark Red
Number of teeth exposed in full grin: _____ Upper _____ Lower
Model of Pickup owned: _____________ Height of Truck: ________
Truck is equipped with: * Gun Rack * Raccoon Hide * 8-track * Fuzz Buster * Spittoon * Mud Flaps * 4-Wheel Drive * Toothpick holder * Load of Wood * Mag Wheels * Camper Top * Big Dog * Confederate Flag * Hijacker Shockers * Dual CB Antenna * Air Horns * Mud-grip Tares * Other:
Number of Empty Beer Cans on floor of pickup: __________________
Bumper Stickers: * Wave if You're Horny * Honk If You Love Jesus * Eat More Possum * Peanut Butter * Redman Chewing Tobacco * Other:
Define the Following: 1. Grits 2. Goobers 3. Collards 4. Sidemeat 5. Chitlins 6. Shit-on-a-Shingle 7. Sawmill Gravy 8. Muscadins 9. Brogans 10. Redeye Gravy 11. Soppin' Gravy 12. Cobbler 13. Fatback 14. Tote 15. Poke 16. Cracker 17. Tater 18. Pig Skins 19. Pinto Beans 20. Turnip Salit
Favorite Vocalist: * Donna Fargo * Porter Wagner * Johnny Cash * Hank Williams * Conway Twitty * Willie Nelson * Tammy Wynette * Elvis * Loretta Lynn * George Jones * Box Car Willie * Slim WhitmanOther:
Favorite Recreational Activity:
* Square Dancin' * Craw Daddin' * Drankin' * Blue Grass Conventions * Possum Huntin' * Gospel Singin' * Spittin' Backy * Skinny Dippin' * 4-Wheelin' * Bull Chip Throwin' * Other:
Weapons Owned: * Deer Rifle * Tar Arn * Sawed-Off Shotgun * Bid Gun * Pick Handle * Varmit Rifle * Log Chain * Big Wife * Chain Saw * Other:
Number of Hound Dogs: __________________________________________
Cap Emblem: * John Deere * Saville's AMOCO * McCulloch Chain Saws * CAT * Coors * Budweiser * Skoal * NAPA * Viet Nam Vet * Other:
Number of Weeks Unemployed: ____________________________________
Number of Weeks Admitted to: ___________________________________
Number of Welfare Checks Received: _____________________________
Number of Dependents: Legal _____ Claimed ____ Accused of ____
Memberships: * KKK * VFW * NRA * Bass Club * Moose * PTL Club * Elks * American Legion * United Sons/Daughters of the Confederacy * Other:
Length of your Right Leg: _____ Length of your Left Leg: _____
Does your truck contain some part painted in the official state color, primer red? * Yes * No
How many cars do you have jacked up on blocks in your front yard? _________________________________________________________________
How many kitchen Appliances (working or not) do you keep on the front porch? ___________________________________________________
Do you have old tares or throw-away commodes in your front yard being used as flower planters? * Yes * No Are they still usable? * Yes * No
Do You qualify as part of the West Virginia Intelligentsia - with a measurable IQ? * Yes * No
Do you wear mostly double-knot polyester pants with snags? * Yes * No
Do You own any shoes? * Yes * No How Many? ________ When did you last purchase any? __________
Are you married to: * Sister * Cousin * Sow * Other:
Do you know her name? * Yes * No Do you care? * Yes * No
Does your wife weigh more than your pickup? * Yes * No
Can you sign your name and get the spelling right every time: * Yes * No
Have you ever stayed sober for a whole weekend? * Yes * No If "No", why not? ______________________________________________
Can you count past ten with your shoes on? * Yes * No
How about twenty-one with your fly up? * Yes * No
Do you have at least two of the following: * Scabies * Trench Mouth * BO * Funny Nose * Crabs * Bad Breath * Head Lice * Other:
Do you know any words that have more than four letters? * Yes * No
Have you ever had more than one bath in a week? * Yes * No If "Yes", why? _________________________________________________
Have you heard that the 29th Street Bridge in Huntington is being torn down because there's too much arch in it? * Yes * No
If "Yes", how long have you known this? ________________________
When riding down the road as a passenger, do you hang your foot out the window without socks or shoes for any of the following reasons: * To signal a right turn for your bud. * To air your Toes. * To adjust the meer. * Other:
In your opinion, "Mountaineers Are Always Free" means: * West Virginians don't cost very much. * West Virginians will not be bridled and controlled by Yankee-type SOB's! * Other: _____________________________________________________