Application to live in Mississippi

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'RE HORNY                    ( ) HONK IF YOU LOVE JESUS

( ) ALMOST HEAVEN, BUCKSPORT                ( ) SNATCH KISSES AND VICE VERSA

( ) OLD FART                                ( ) I LOVE HINEY WINE

( ) SHIT HAPPENS                            ( ) REDMAN CHEWING TOBACCO

( ) WOOD IS WONDERFUL                       ( ) SAVE THE BLACK FLY

( ) DON'T LIKE MY DRIVING?  CALL 1-800-EAT-SHIT

( ) ALL YOU ECOLOGICAL BASTARDS 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         ( ) EAT ME



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



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



DOES YOUR WIFE WEIGHT 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.           ( ) CRABS             ( ) HEAD LICE        ( ) BAD BREATH

( ) SCABIES        ( ) YELLOW TEETH      ( ) GREEN TEETH      ( ) FLEAS

( ) RUNNY NOSE     ( ) TATTOOS           ( ) CROSSED EYES     ( ) STUTTER







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

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