NAME:_______________________ AGE:________________
ADDRESS:____________________ PHONE:______________
CITY:_______________________ PROVINCE:___________
NAME OF CHURCH:_____________________________________
# OF TIMES ATTENDED LAST YEAR:______________________

1.)Do you drive( )Sports Car ( )Van ( )Station Wagon ( )Motorcycle
(If you checked any of the above,put the pen down,walk slowly to the door,and run as fast as you can

2.)Please complete this sentence:THE PLACE FOR A WOMAN IS:
_______________________________________________________

3.)In 50 words or less,describe what "NO" means to you:
_______________________________________________________

4.)In 50 words or less,describe what "LATE" means to you:
_____________________________________________________

5.)Describe where you would least like to be shot:
_______________________________________________________

6.)Have you ever had you testicles( )removed ( )crushed
( )placed in vise grips ( )shredded?

7.)Which is the last bone you would like broken:__________________________

8.)Have you ever thought how you would do things with broken fingers?____________

9.)What do you want to be "IF" you ever grow up?____________________

10.)Have you ever thought about what it would be like to be:
( )quadriplegic ( )permanently scarred ( )crippled for life.

11.)Have you ever seen my hunting rifle?_____________________________

12.)Do you know the effective range of a 30.06?__________________

NEXT OF KIN:___________________________________________
FUNERAL HOME(OR BODY REMOVAL SERVICE) OF CHOICE:_______
WOULD YOU LIKE TO BE AN ORGAN DONOR? ( )YES ( ) NO

~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*~*

PARENTAL USE ONLY

LOOKS LIKE: ( )MEL GIBSON ( )DENNIS RODMAN ( )PEEWEE HERMAN

STATUS: ( )ACCEPTED ( )REJECTED ( )ARRESTED ( )TERMINATED

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