Arkansas State Census

Name: ________________

(_) Billy-Bob

(last)

(_) Billy-Joe
(_) Billy-Ray
(_) Billy-Sue
(_) Billy-Mae
(_) Billy-Jack
(_) Billy-Jefferson

(Tick appropriate box)

Age: ____
Sex:
(_) M
(_) F
(_) N/A
Shoe Size: ____ Left ____ Right

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

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)

Vehicle Information

___ 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: ___________194_

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

___ 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
(_) Not Applicable

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
(_) don't know