It is not necessary to attach a photo since you all look alike.

NAME________________________________________________ DATE___________________________

(If living in automobile give make, model & license number)

NAME OF MOTHA________________________________ NAME OF FATHA_________________________
                                                             (If known)

MAKE OF AUTOMOBILE:  Cadillac_____________Lincoln_____________Imperial______________

Number of children claimed on Welfare_______________________________________________

Number of legitimate Children (If Any)______________________________________________

Marital Status:          Common Law________   Shacked Up_________________

Place of birth:    Charity Hospital________  Cotton Patch________________
                   Zoo_____________________  Back Alley__________________

                   Free Public Hospital__________________________________

Approximate Estimate of Income:  Welfare $______ Unemployment $__________
                                 Theft $________

How many words do you jive a minute?____________________

Check machines you can operate: Typewriter______________ Adding Machine_____________

                                Telecopter______________ Rubber Machine_____________

                                Switch Blade____________ Cotton Hoe_________________

                                Pistol__________________ Television_________________


Check foods you like best:      Bar-B-Q_________________ Watermelon_________________

                                Carp____________________ All of the Above___________

Check illnesses you may have had in the last year:  Measles___________Mumps_________


                                                    Food Stamp Poisoning____________

Abilities:    Government Employee_____________  Demonstration Leader________________
              Evangelist______________________  Venereal Disease Spreader___________
              Tap Dancer______________________  Singer______________________________
              Dope Pusher_____________________  Pimp________________________________

              All of the Above________________

In 50 words or less, describe your greatest desire in life: (other than a white girl)

I,__________________________________, swars that the jive asked above is answered to
        ( X or signature )
the best of this niggers ability, and that I swars that I will always look like a
nigger, dress like a nigger, act like a nigger, and smell like a nigger.  I believes
in the NAACP concept of equality, that niggers is better than white folks is.  I
promise to do everything in my power to increase the nigger population, so help me Lawd!


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