APPLICATION TO LIVE IN WEST VIRGINIA

Name: ________________  Nickname: ______________  CB Handle: ___________

Address (RFD No.): _____________________________________________________

Daddy (If unknown, attach list of 3 suspects): _________________________

Mamma: ______________  Neck Shade ( ) Light Red ( ) Medium Red ( ) Dark Red

Number of teeth exposed in full grin:  Upper ___________  Lower _________

Name of Pickup Truck Owned: ___________________  Height of Truck: ________

Truck equipped with:

( ) 8 - Track   ( ) Load of Wood  ( ) Hijacker shocks  ( ) Mud-Grip Tires
( ) Fuzz Buster ( ) Mag Wheels    ( ) Dual CB Antennas ( ) Racoon Hide
( ) Spittoon    ( ) Camper Top    ( ) Air Horns        ( ) Big Dog
( ) Mud Flaps
    
Number of empty beer cans on floorboard of pickup: ______________________

Bumper Stickers: ( ) Eat More Possum  ( ) Peanut Butter
                 ( ) Honk If You Love Jesus  ( ) Wave If You're Horney
                 ( ) Redman Chewing Tobacco

Define the Following (must be 90 percent correct):

1.  Gritts     6.  Muscadine       11.  Cobbler      16.  Tater
2.  Goobers    7.  Brogans         12.  Fatback      17.  Pig Skins
3.  Collards   8.  Redeye Gravy    13.  Tote         18.  Pinto Beans
4.  Sidemeat   9.  Sawmill Gravy   14.  Poke         19.  Turnip Salit
5.  Chitlins   10. Soppin Syrup    15.  Cracker      20.  Well Water

Favorite Vocalist:

( ) Box Car Willie   ( ) Conway Twitty  ( ) Loretta Lynn   ( ) Donna Fargo
( ) Elvis            ( ) Johnny Cash    ( ) Tammy Wynette  ( ) George Jones

Favorite Recreation:

( ) Square Dancin' ( ) Possum Huntin' ( ) Skinny Dippin' ( ) Craw Daddin'
( ) Gospel Singin' ( ) 4 - Wheelin'   ( ) Drankin'       ( ) Spittin' Backy
( ) Blue Grass Conventions            ( ) Bull Chip Throwin'

Weapons Owned:

( ) Deer Rifle  ( ) Bird Gun   ( ) Varmit Rifle   ( ) Log Chain
( ) Chain Saw   ( ) Tire Iron  ( ) Pick Handle    ( ) Sawed-off Shotgun

Number of Hound Dogs: _______ Type: ( ) Blue Tick ( ) Black & Tan ( ) Beagle

Cap Emblem:  ( ) John Deere  ( ) CAT     ( ) McCollough Chain Saws
             ( ) Budweiser   ( ) NAPA    ( ) Coors

Number of Weeks Unemployed: ______ Number of Welfare Checks Recieved: _____

Number of Dependents:  (Legal) ___________ (Claimed) _____________

Memberships:  ( ) NRA       ( ) Moose        ( ) PTL Club      ( ) VFW
              ( ) Bass Club ( ) United Sons/Daughters of the Confederacy

Length of Right Leg: ________________  Length of Left Leg: ______________

Does your truck contain some part painted the
official state color, Primer Red? _________________

How many cars do you have jacked up on blocks in your front yard? _________

How many kitchen appliances (working or not) will you keep
on your front porch? ______________

Will you be a part of the West Virginia Intelligentsia
with a measurable IQ? ________________

Do you wear mostly double knit polyester pants with snags? _____________

Do you own any shoes, if so, how many? _______
What year did you last purchase shoes? ________

Are you married to any of the folling:

Sister _______  Cousin ________  Sow __________ Do you know her name? _____

Does your wife weigh more than your pickup? _________

Does your wife weigh more than your pickup? _________

Can you sign your name and get the spelling right every time? _____________

Have you ever stayed sober for a whole weekend? _______________
       
Can you count:  Past 10 with your shoes on? _________________
                to 21 with your fly up? _________________

Medical Information:

Do you have at least 2 of the following:  BO __________ Crabs ___________

Head Lice ________  Scabies ________  Trench Mouth ___________

Runny Nose __________  Bad Breath ________

Do you know of any words that have more than 4 letters? ___________

Have you EVER had more than one bath a week? ______________