2010 Census for Southeast Texas

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 appropriate box)
(_) 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:
(_) Blond
(_) Black
(_) Red
(_) Brown
(_) White
(_) Clairol

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