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: _____________
Number of empty beer cans on floorboard or in bed ofpickup: ________
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
BUMPER STICKERS:___ Eat more Possum___ My other car is a piece of junk too
___ Honk if you love Jesus___ If you ain't a cowboy, you ain't nothin'
___ Red-man Chewing Tobacco
Favorite Recreation: Check all that apply:___ Square Dancin' ___ Possum Huntin'
___ Skinny Dippin'___ Craw Daddin'___ Gospel Singin' ___ 4-Wheelin'___ Drankin' ___ Spittin' Backy ___ Bill Chip Trowin' ___ Honky Tonkin'___ Noodlin'
# 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
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