The 2010 Federal Census Form (Arkansas Residents Only)

[hyakugojyuuichi]

THE 2010 FEDERAL CENSUS FORM (ARKANSAS RESIDENTS ONLY)

Last name: ________________
First name: (Check appropriate box)
(_) Billy-Bob (_) Billy-Joe (_) Billy-Ray (_) Billy-Sue
(_) Billy-Mae (_) Billy-Jack

What does everyone call you?
(_) Booger (_) Bubba (_) Junior (_) Sissy
(_) Other___________________

Age: ____ (if unsure, guess)
Sex: ____ M _____ F _____ Not sure
Shoe Size: ____ Left ____ Right

Occupation: (Check appropriate box)
(_) Farmer (_) Mechanic (_) Hair Dresser
(_) Dirty Politician (_) Preacher (_) Unemployed

Spouse's Name:_________________________
2nd Spouse's Name:______________________
3rd Spouse's Name:______________________
Lover's Name:___________________________
Relationship with spouse: (Check appropriate box)
(_) Sister (_) Brother (_) Aunt (_) Uncle (_) Cousin
(_) Mother (_) Father (_) Son (_) Daughter (_) Pet

Number of children living in household: _____
Number of children living in shed: ______
Number that are yours: ______

Mother's Name: _______________________(If not sure, leave blank)
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: ___
Firearms you own and where you keep them:
____ truck ____ bedroom ____ bathroom
____ kitchen ____ shed

Model and year of your pickup: 196_

Do you have a gun rack?
(_) Yes (_) No (If no, please explain)

Newspapers/magazines you subscribe to:
(_) The National Enquirer (_) The Globe (_) TV Guide
(_) Soap Opera Digest (_) Rifle and Shotgun

Number of times you've seen a UFO:_____
Number of times in the last 5 years you've seen Elvis:_____
Number of times you've seen Elvis in a UFO:_____

How often do you bathe:
(_) Weekly (_) Monthly (_) Not Applicable

Color of eyes:
Left______ Right_____

Color of hair:
(_) Blond (_) Black (_) Red (_) Brown (_) White (_) Clairol

Color of teeth:
(_) Yellow (_) Brownish-Yellow (_) Brown (_) Black (_) N/A

Brand of chewing tobacco you prefer:
(_)Red-Man

How far is your home from a paved road?
(_) 1 mile (_) 2 miles (_) just a whoop-and-a-holler (_) road?

Signature (your mark) _____________________________

[dnyed]

Haha!