Charldine Club [International]
Anonymous Associated Membership.
 $25.00/six months. (US Dollars in cash)
Down-load: Print and mail to CCI  POBx 262 Delanson, NY 12053

Last name: 
(_) Smith  (_) Jones
(Check appropriate box)

First name:
(_) Billy-Bob
(_) Billy-Ron
(_) Billy-Joe
(_) Billy-Ray
(_) Billy-Sue
(_) Billy-Mae
(_) Billy-Jack
(_) Billy-Elvis
(Check appropriate box)

Age: ____   Sex: ____ M _____ F _____ not sure______
Shoe Size: ____ Left ____ Right
Occupation:
(_) Rock Farmer
(_) Back-yard Mechanic
(_) Dog & Cat Hair Dresser
(_) Unemployed

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 pop-up home? (Check appropriate box)
Model and year of your pickup: _____________ 194_
Do you have a gun rack? (_) Yes (_)No;
       If no, please explain:______________________________________

 ___ 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 firearms you own and where you keep them:
 ____ truck
 ____ bedroom
 ____ bathroom
 ____ kitchen
 ____ shed

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 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 teeth:
(_)Yellow (_)Brownish-Yellow (_)Brown (_)Black (_)N/A

Brand of chewing tobacco you prefer: (_)Red-Man (_)Other

How far is your home from a paved road?
(_)1 mile (_)2 miles (_)don't know

By my signature below, I agree to have sexual contact with all
and any willing respondents.
Please scribble you name so no others may read it.
     X_______________________________
Start Date for membership term; ____________________