USA 2010 Census

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The 2010 Federal Census For The South

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

(_) Unemployed

(_) Dirty Politician

(_) Preacher

Spouse's Name:_________________________ 2nd Spouse's Name:______________________ 3rd Spouse's Name:______________________ Lover's Name:___________________________

Relationship with spouse: (Check all that apply)

(_) 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:

(_) Blonde

(_) Black

(_) Red

(_) Brown

(_) White

(_) Clairol

Color of teeth:

(_) Yellow

(_) Brownish-Yellow

(_) Brown

(_) Black

(_) N/A

Brand of chewing tobacco you prefer:

(_)Red-Man

(_)Skoal

(_)Coppenhagen

How far is your home from a paved road?

(_) 1 mile

(_) 2 miles

(_) just a whoop-and-a-holler

(_) road?

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