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Southern Census Form |
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First
name: (Check appropriate box)
Occupation:
[ ]
Billy-Bob
[ ] Bobby-Ann
[ ] Farmer
[ ] Hair Dresser
[ ]
Billy-Jack
[ ] Bobby-Beth
N/A
[ ]
Billy-Joe
[ ]
Bobby-Ellen [ ]
Waitress [
] Unemployed
[ ]
Billy-Mae
[ ] Bobby-Jo
[ ]
Billy-Sue
[ ] Bobby-Lee
[ ]
Billy-Ray
[ ]
Bobby-Sue Age:
____ (if unsure, guess)
Sex: ____ M _____ F _____ (if unsure, guess) Shoe
Size:
Left ____
Right ____
Not Applicable ____ Spouse's Name:
__________________________ 2nd Spouse's Name:
_______________________ 3rd Spouse's Name:
_______________________ Relationship to Spouse(s):
(Check all that apply)
[ ]
Aunt [
] Brother
[ ]
Cousin
[ ]
Daughter
[ ]
Father [
] Mother
[ ]
Pet [
] Sister
[ ]
Son [
] Uncle Lover's Name:
____________________________ 2nd Lover's Name:
________________________ Relationship to Lover(s):
(Check all that apply)
[ ]
Aunt [
] Brother
[ ]
Cousin
[ ]
Daughter
[ ]
Father [
] Mother
[ ]
Pet [
] Sister
[ ]
Son [
] Uncle Number of children living in
household: ___ Number of children living on
premises: ___ Number that are yours: ____
(probable number acceptable) Mother's Name:
_______________________ (if
known) Father's Name:
________________________ (If not sure, leave blank) Education:
1 2
3 4 5
(Circle highest grade completed) SOUTHERN
CENSUS FORM (page
2) Do you own [ ]
or rent [ ]
your mobile home? (Check appropriate box) Total
number of vehicles you own ____
Total number of vehicles on your land ____ Number
of vehicles that still crank ____
Number of vehicles on cement blocks ____ Number
of vehicles in front yard ____
Number of vehicles in back yard ____ Where you keep firearms:
(Check all that apply)
[ ]
Bathroom [
] Bedroom
[ ]
Kitchen
[ ]
Shed
[ ]
Tractor
[ ]
Truck
[ ]
All of the above Model and year of your
pickup: _____________________ 194__ Do you have a gun rack?
[ ]
Yes [
] No
If no, please explain:_________________ Newspapers/magazines you
read:
[ ]
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 ____ Number of times you've been
abducted by a UFO ____ How
often do you bathe:
Color of teeth:
[ ]
Weekly
[ ]
Yellow [
] Brownish-Yellow
[ ]
Monthly
[ ]
Brown [ ] Black
[ ]
Not Applicable [ ] Not
Applicable Brand of chewing tobacco you
prefer:
[ ]
Red-Man
[ ]
Other How far is your home from a
paved road?
[ ]
1 mile
[ ]
2 miles
[ ]
don't know
[ ]
Never seen a paved road
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