West Virginia State Residency Application

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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: _____________

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




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