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

---------------------------------------------------------------------------