APPLICATION TO LIVE IN

PAHRUMP, NEVADA

The followin’ information will determine your eligibility to reside in the greater city of Pahrump, Nevada.

Name:_____________________________________________

Nickname:___________________________ C.B. Handle:______________________________

Father (if unknown, list 3 suspects): _________________________________________________

Neck Shade: ( ) Light Red ( ) Medium Red ( ) Dark Red

Number of exposed teeth in full grin: upper____ lower_____

Make and Model of pickup:________________________ Size of tires:_______________

Number of empty beer cans in pickup: floor______________ bed___________________

Is truck equipped with any of the followin’:

( ) Gun rack ( ) Beer decals ( ) American flag ( ) Mud flaps

( ) Hijack shocks ( ) 8-track ( ) Camper top ( ) Fuzz buster

( ) Mud tires ( ) C.B. antennas ( ) Roll bar

Bumper stickers displayed:

( ) Honk if you’re horny ( ) I Love Nevada ( ) Honk if you love Jesus

( ) Old Fart ( ) I eat road kill ( ) I snatch kisses and vice-versa

( ) I may be slow, but I’m ahead of you ( ) Dial 1-800-EAT-SHIT

( ) Don’t argue with your wife, just dicker

Favorite beverage:

( ) Coors ( ) Miller Lite ( ) Pabst ( ) Jack Daniels

( ) Bud ( ) Pahrump tap water ( ) Pepsi ( ) well water

Favorite chewin’ tobacco:

( ) Skoal ( ) Skoal Bandit ( ) Copenhagen ( ) Happy Days

( ) Red Man ( ) whatever

Favorite Singer:

( ) Elvis ( ) Conway Twitty ( ) Willie Nelson ( ) Johnny Cash

( ) Loretta Lynn ( ) Grampa Jones ( ) Other

Favorite Recreation:

( ) Drinkin’ ( ) Square Dancin’ ( ) Drinkin’ ( ) Fishin’

( ) Swap meet ( ) Drinkin’ ( ) Yard Sales ( ) Drinkin’

Your weapon of choice:

( ) Tire iron ( ) Axe Handle ( ) Shotgun ( ) Wood Club

Emblem on your hat:

( ) NRA ( ) John Deere ( ) Cat

( ) Eagles Club ( ) American Legion ( ) Elks Club

( ) Favorite beverage (see above) ( ) Favorite chewin’ tobacco (see above)

Memberships:

( ) NRA ( ) KKK ( ) VFW ( ) PTL ( ) 700 Club

How many cars in front yard:________ on blocks:___________

When was your last Elvis sightin’:____________

Do you wear polyester pants: ( ) Yes ( ) No

Levis: ( ) Yes ( ) No

Do you own shoes (besides boots): ( ) Yes ( ) No

Are you married to any of the followin’: (check all that apply)

( ) sister ( ) cousin ( ) cousin’s sister

Does your spouse weigh more than your pickup: ( ) Yes ( ) No

Can you sign your own name: ( ) Yes ( ) No

Do you always spell your name corrrectly: ( ) Yes ( ) No

Do you sign your name with a big or a small ‘X’: ( ) Big ( ) Small

Have you ever stayed sober for a whole weekend: ( ) No

Can you count past 10 with your shoes on: ( ) Yes ( ) No

Can you count past 20 with your fly closed: ( ) Yes ( ) No

Have you ever had more than 1 bath a week: ( ) Yes ( ) No

Do you live on a dirt road: ( ) Yes ( ) No

If so, does it have a name: _____________ ( ) Yes ( ) No

How many kitchen appliances do you intend to keep on your front porch:_________

Number of hounds:_____________

Type: ( ) Blue Tick ( ) Beagle ( ) Black and Tan

Do you have at least two of the followin’: (check all that apply)

( ) B.O. ( ) Lice ( ) Bad Breath ( ) Scabies

( ) Runny Nose ( ) Tattoos ( ) Crossed Eyes ( ) Fleas

( ) Black teeth ( ) Brown teeth ( ) Yellow teeth ( ) Crabs

Are the wheels still on your house or have they been took off: ( ) Yes ( ) No

Is your sisters name and number still on the bathroom wall at the truck stop: ( ) Yes ( ) No

Please sign (one ‘X’ will do):______________________________________Date:_____________