It isn't necessary to attach
a photo since you all look alike.

Name: _________________________________________
Address:  _____________________________________
(If living in automobile, give make, model, & license number)
Gang: _________________________________________

Name of Mutha: ______________________
Name of Fatha (if known): _____________________

Type of building in which you live:  Shack ___  Ghetto slum ____  Public housing ___
Homeless shelter ___  Cardboard box ___

Place of Birth:  Charity Hospital ___  Free Public Hospital ___  Cotton Patch ___
Back Alley ___  Zoo ___

Education (if any):  Grade school ___  High School ___  College ___
If college, how financed?  Basketball scholarship ___  United Negro College Fund ___

Marital Status:  Single ___  Common-law ___  Shacked-up ___

Number of known children you have:  1st wife: _____  2nd wife: _____  3rd wife: _____
Neighbor's wife: _____  Shack-ups: _____

Check qualifications you have:  Preacher ___  Gov't employee ___  Demonstration leader ___
Hubcap salesman ___  Rapist ___  Waterbed demonstrator ___  Gang leader ___
Controlled substances distributor ___

How many words do you rap a minute? _____

Current legal status:  On parole ___  Out on bail ___  Fugitive ___  Other ___

Check illnesses you have had in the past year:  VD ___  HIV ___  Food stamp poisoning ___

Type of auto you drive:  Cadillac ___  Lincoln ___  BMW ___  Other ___________________
Was this car:  Financed? ___  Stolen? ___
If financed, give repossession date: __________________

Check foods you like best:  Barbeque ___  Fried chicken ___  Carp ___  Coon ___
Possum ___  Chitlins ___  Watermelon ___  Muskrat ____

List your estimated yearly income:  Theft $_______   Welfare $_______  Unemployment $_______

List your greatest desire in life (other than a white girl): ________________________________