WEST VIRGINIA STATE RESIDENCY APPLICATION

  Name: ________________
                (last)
                (first)   (_) Billy-Bob
                          (_) Billy-Joe
                          (_) Billy-Ray
                          (_) Billy-Sue
                          (_) Billy-Mae
                          (_) Billy-Jack
                          (Check appropriate box)
  Age: ____
  Sex: ____ M _____ F _____ N/A
  Shoe Size: ____ Left ____ Right

  CB Handle: _____________________

  Occupation:
  (_)Farmer
  (_)Mechanic
  (_)Hair Dresser
  (_)Un-employed
  (_)Coal Miner

  Spouse's Name: __________________________

  Relationship with spouse:
  (_) Sister
  (_) Brother
  (_) Aunt
  (_) Uncle
  (_) Cousin
  (_) Mother
  (_) Father
  (_) Son
  (_) Daughter
  (_) Pet

  Number of children living in household: ___

  Number 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)

  ___ 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
  ___ Number of refrigerators on front porch

  Firearms you own and where you keep them:
  ____ truck
  ____ bedroom
  ____ bathroom
  ____ kitchen
  ____ shed

  Model and year of your pickup: _____________ 194_
  Number of empty beer cans on floorboard or in bed of pickup: _________

  Newspapers/magazines you subscribe to:
  (_)The National Enquirer
  (_)The Globe
  (_)TV Guide
  (_)Soap Opera Digest
  (_)Gun World

  ___ 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
  (_)Holidays
  (_)Not Applicable

  Color of teeth:
  (_)Yellow
  (_)Brownish-Yellow
  (_)Brown
  (_)Black
  (_)No teeth
  (_)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
  (_)can't get there from here

  Reason for continued residence in West Virginia:
  (_) can't bear to leave brother's behind
  (_) daddy won't give me my pants back
  (_) liberal wife beating laws

 BUMPER STICKERS:
  ___ Eat more Possum                    ___ My other car is a piece of shit too
  ___ Honk if you love Jesus             ___ If you ain't a cowboy,
you ain't shit
  ___ Red-man Chewing Tobacco            ___ Wave if you're horny

 Favorite Recreation:
  ___ Square Dancin'  ___ Possum Huntin'    ___ Skinny Dippin'
  ___ Craw Daddin'    ___ Gospel Singin'    ___ 4-Wheelin'
  ___ Drankin'        ___ Spittin' Backy    ___ Bill Chip Trowin'
  ___ Honky Tonkin'   ___ Noodlin'          ___ Other

 Number of Dogs: ___ Type: ___ Blue Tick    ___ Beagle
                           ___ Black & Tan  ___ Bird Dawg

 Cap Emblem: ___ John Deere  ___ McCulloch Chain Saws  ___ Budweiser
             ___ Vo-Tech     ___ Skoal                 ___ Coors
             ___ NAPA        ___ Smile if you're Not Wearing Underwear

 Memberships:
  ___ KKK  ___ NRA  ___ Moose  ___ PTL Club  ___ AA
  ___ Bass Club  ___ VFW  ___ Quiltin' Bee  ___ American Legion
  ___ United Sons/Daughters of the Confederacy
  ___ John Birch Society

 Medical Information:
 Do you have at least two of the following:
 ___ B.O.  ___ Crabs  ___ Head Lice   ___ Rabies
 ___ Trench Mouth  ___ Runny Nose   ___ Bad Breath ___ Chafing

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