State of West Virginia Reisdency Application

Last Name: ________________ 

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

Age: ____, if known
Sex: ____ M _____ F _____ N/A
Shoe Size: ____ Left ____ Right 

Occupation: (phonetic spellings available) 
    (_) Farmer
    (_) Mechanic
    (_) Hair Dresser
    (_) Un-employed

Spouse's Name: __________________________ 

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

Number of children living in household (If you can count) : ___ 
Number that are yours: ___

Mother's Name: _______________________ 

Father's Name: _______________________ (If not sure, leave blank) 

Relation of mother to father: _________________

Education: 1 2 3 4 (Circle highest grade completed) 

Do you (_)own or (_)rent your mobile home?  (Check appropriate box) 
Does it have wheels? (_)
How many tornadoes has it been through? (_) 

___ 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 shirts you own. (1.. 2)
Number of shirts that are tank tops with motorcycles on them(_)

What does your foam hat say? 
    (_) John Deer
    (_) If I have anything to say to you I'll fart 
    (_) I own a chevy truck
    (_) Old Fart's Wife
    (_) No longer readable due to filth
    (_) you don't know because you can't read 

Firearms you own and where you keep them: 
    ____ truck
    ____ bedroom
    ____ bathroom
    ____ kitchen
    ____ shed
    ____ church benches ( for when father speaks of the sins of incest) 

Model and year of your pickup: _____________ 194_ 
How many deer have you struck with it? (_)

Do you have a gun rack?
    (_) Yes (_) No; please explain: 

Have you been struck by lightning? (_) 
How many times? (_)
While carrying a firearm? (_) 

What flavors of aqua velva does the local bar serve on tap? 
    (_) springtime blue
    (_) musk
    (_) seaside green

How many of your family members are cross eyed? (__), (_)all. 

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

___ 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
___ Number of times you've shot at Elvis in a UFO
___ Number of consecutive sober days (0,1,2,3, can't remember) 

Do you bathe? (_)
If so, how often do you bathe: 
    (_)Weekly
    (_)Monthly
    (_)Not Applicable

Color of teeth:
    (_)Yellow
    (_)Brownish-Yellow
    (_)Brown
    (_)Black
    (_)No teeth

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

How far is your home from a paved road? 
    (_)1 mile
    (_)2 miles
    (_)don't know


From Oliver Grillmeyer (topramen@garnet.berkeley.edu) 

From "Robbio" Grillmeyer (grillmey@gene.com) 






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