_________________________________________________________________ West Virginia Residency Application _________________________________________________________________ APPLICATION TO LIVE IN THE STATE OF WEST VIRGINIA ------------------------------------------------- 1. Your name is (Check one): ( ) Billy ( ) Calvin ( ) Eli ( ) Harvey ( ) Homer ( ) Jimmie ( ) Junior ( ) Leonard ( ) Leroy ( ) Luther ( ) Oscar ( ) Mordechai a. Nichname:___________________ b. CB Handle:_______________________ 2. Address (RFD#):________________________________________________________ 3. Daddy (If unknown, attach list of 3 suspects):_________________________ 4. Mama:______________________ 5. Number of brothers/sisters_____________ 6. Are you married to: ( ) Sister ( ) Cousin ( ) Sow ( ) Other Relative Do you know her name?__________________________________________ Does your wife weigh more than your truck? ( ) Yes ( ) No ( ) Likely 7. Number of weeks employed:_________ On welfare:________ in the last year. 8. Your neck shade (check one): ( ) Light red ( ) Medium red ( ) Dark red 9. Number of dependents: (Legal)___________ (Claimed) _____________________ 10. Length of Right Leg:_______ inches. Lenght of Left Leg:________ inches. 11. Type of pick-up owned:_________________________________________________ a. Year:____________ b. Height of Truck__________________________ c. Is any portion of your truck painted primer red (The official state color)?_________ What part(s)?________________________________ d. Average number of beer cans on floorboards of pick-up truck:_________________________________________________________ e. Truck equipped with (check all that apply): ( ) Gun rack ( ) 4-wheel drive ( ) Eight Track ( ) Load of wood ( ) Big dog ( ) Fuzz buster ( ) Mag wheels ( ) Dual CB Antenna ( ) Camper Top ( ) Spitoon ( ) Mud flaps ( ) Spit Staines ( ) Bumper hitch ( ) Spit stains ( ) Air horns ( ) Hijacker shocks ( ) Raccoon Hide ( ) Deer Antlers ( ) Confederate flag f. Bumper stickers on truck (regardless of location): ( ) Eat More Possum ( ) Redman Chewing Tobacco ( ) Honk if your love Jesus ( ) Honk if your Horny ( ) Elvis is Alive ( ) My Other car is a piece of s---, too ( ) BOCEPHUS ( ) Get off my Ass ( ) Other:____________________________________________________________ 12. Weapons owned: ( ) Deer Rifle ( ) Scatter Gun ( ) Log Chain ( ) Sawed-off shotgun ( ) Balin' Hook ( ) Varmit Rifle ( ) Axe Handle ( ) Tire Iron a. Which are normally carried on your person?__________________________ b. In your truck?______________________________________________________ 13. Favorite Recreation: ( ) Drankin' ( ) Possum Huntin' ( ) Bull Chip Throwin' ( ) Craw Daddin' ( ) Four Wheelin' ( ) Gospel Sangin' ( ) Skinny Dippin' ( ) Fightin' ( ) Fishin' ( ) Puckin' ( ) Spittin' Backy ( ) Square dancin' 14. Emblem on your favorite cap: ( ) CAT ( ) NAPA ( ) Budweiser ( ) McCullough ( ) Coors ( ) John Deer ( ) P. B. R. ( ) Skoal 15. Define the following (must be 90% correct): a. brogans - ____________________________________________ b. chitlins - ____________________________________________ c. cobbler - ____________________________________________ d. fatback - ____________________________________________ e. goobers - ____________________________________________ f. collards - ____________________________________________ g. grits - ____________________________________________ h. muscadina - ____________________________________________ i. pig skins - ____________________________________________ j. pinto beans - ____________________________________________ k. poke - ____________________________________________ l. redeye gravy - ____________________________________________ n. s--- on a shingle - ____________________________________________ o. sidemeat - ____________________________________________ p. soppin' syrup - ____________________________________________ q. spam - ____________________________________________ r. taters - ____________________________________________ s. tote - ____________________________________________ t. turnip salad - ____________________________________________ 16. Favorite Sanger: ( ) Donna Fargo ( ) Conway Twitty ( ) Jonny Cash ( ) Elvis (mandatory) ( ) Hank Junior ( ) Loretta Lynn ( ) Porter waggoner ( ) Willie Nelson ( ) George jones ( ) Slim Whitman ( ) Tammy Wynette ( ) Boxcar Willie 17. Club Memberships: ( ) K.K.K. ( ) N.R.A. ( ) 700 Club ( ) P.T.L. ( ) Four H ( ) B.A.S.S. ( ) Sons of the confederacy (mandatory) 18. Number of dogs owned (Do not include kinfolk):______________________ Type: ( ) Blue Tick ( ) Beagle ( ) Redbone ( ) Black 'n' Tan ( ) Mutt 19. Number of cars on block in front yard:_________________________________ 20. How many kitchen appliances do you keep on your front porch?____________ How many of them work?_____________________ 21. Do you wear: ( ) snagged polyeter pants ( ) denim britches ( ) shorts 22. Do you own any shoes? ( ) Yes ( ) No If so, hom many?_____________ Year you last bought shoes:__________________________ 23. Highest grade completed in school: _______________ If higher than 8th grade, reason why:___________________________________________________ 24. Can you sign your name and spell it correctly every time? ( ) Yes ( ) No ( ) Maybe 25. Do you know any words that have more than four letters? ( ) Yes ( ) No If so list them here:___________________________ 26. Have you ever had more than one bath in a week? ( ) Yes ( ) No ( ) What's a bath 27. Can you count past ten with your shoes on? ( ) Yes ( ) No ( ) never tried .....past twenty with your fly up? ( ) Yes ( ) No ( ) never tried 28. What do you prefer to drink? ( ) Iced tea ( ) Budweiser ( ) Everclear ( ) Mad Dog 20/20 ( ) Jack daniels ( ) Boones's farm ( ) Jim Beam ( ) Rotgut Moonshine ( ) Coors 29. Have you ever stayed sober for a whole weekend? ( ) Yes ( ) No If so, why?_____________________________________________________ 30. Medical Information: a. Do you have any of the following? (check all that apply): ( ) trench mouth ( ) bad breath ( ) crotch crickets ( ) body odor ( ) runny nose ( ) head lice ( ) missing front teeth ( ) obvious warts ( ) crabs b. Do you show any of the following classic signs of inbreeding? Check all that apply (Minimum three required): ( ) Closely-set eyes ( ) Misaligned ears ( ) Hairs Shoulders ( ) Vacant Stare ( ) Low Forehead ( ) Slight Limp ( ) Slack Jaw ( ) Speech Impediment ( ) IQ of a Carrot I certify that the above information is true and correct to the best of my knowledge. Signature ("X" must be witnessed): _____________________________________ Witness (if "X" is used): _____________________________________ Today's Date (if known): _____________________________________ _________________________________________________________________ pjf@cts.com