Name:____________________________    Nickname:__________________________

CB Handle:______________________

Address (miles from town/grid road):
__________________________________________________________________________

Pa (If unknown, list two best suspects):
_________________________________________________________________________

Neck Shade:    Light Red__        Medium Red__        Dark Red__        Other__

Number of teeth exposed in full grin:        (upper)________________    (lower)_________________

Make and Model of Pickup:________________________    Size of Tire:_______________________

Dogs:_________        Type (if known):_________________

How many trucks in yard?___________________________    How many on blocks?_____________

Do you think Collin Thatcher is guilty?        ____ yes        ____ probably

How often do you write Anne Murray? ________    How many times arrested for it? ____________

Do you wear:        ____ Blue Jeans        ___ Polyester pants with snags
                              ___ Other, explain_______________________________

Do you own any shoes (not boots)         ___ Yes        ___ No

Size of Belt Buckle:    Width:_________    Length:_________    Weight:__________

Does your wife weigh more than your pickup?        ___ yes    ___ no

Can you sign your name and ALWAYS spell it correctly?    ___ yes    ___ no

Have you EVER had more than one bath in the same week?    ___ yes    ___ no
 
 

Medical Information

Do you have at least two (2) of the following?

__ B.O.    __Crabs    __Gas    __Bad Breath    __Fleas    __Tan line around collar/arms    __Crossed Eyes

__Runny nose    __Green Teeth    __Brown Teeth    __Yellow Teeth    __Any Teeth

__Number of Teeth Missing
 

General Information

Can you count past 10 with your shoes on?    __ yes    __ no        Past 21 with your fly up?    __yes    __no

Favourite Weapon:    __Hockey stick    __2x4    __22    __Shotgun    __Baseball bat

Favourite Pastime:    __Drinkin'    __Gopher Huntin'    __Curlin'    __Other

Truck Equipped With    __Gun Rack    __Fuzzbuster    __Cassette Deck    __Booster Cables    __Roll Bar
                                        __8 Track  __CB Radio    __Beer Bottles    __Fuzzy Dice or Garter

Favourite Music:    __Country    __Western    __Anne Murray

Bumper Stickers:    __Honk if you love Jesus    __Damned Government    __Damned Weather
                                  __Damned Banks    __Old Fart

Cap Emblems:        __John Deere    __CAT    --POOL    __Labatts Blue    __Old Fart

Membership:          __Ducks Unlimited    __Legion    __4H    __Co-op    __N.R.A.
 

Signaure (one "X" will do)____________________________________________