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 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?
