NAME: john bubba belcher
ADDRESS: 2 bumpyto drive lot 4
CITY: dirtpoorville STATE: se ZIP: xyz
HOME PHONE#: phone got disconnected
BUSINESS ADDRESS: ain’t got no job
FAX #: who’s fax?
SOCIAL SECURITY #: 555-2640
DRIVER’S LICENSE #: license taken for dui
PHYSICIAN: all them doctors at the er
DENTIST: ain’t got no teeth
ALLERGIES: red’s fleas, my ol’ lady’s feet, and that stuff that’s in all them dang flowers
IN CASE OF EMERGENCY NOTIFY
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NAME: Calvin moonshiner jr
ADDRESS: 2 drunkto drive lot 3
the boonies se 12300
PHONE NUMBER: he ain’t got no phone neither
RELATION TO YOU: brother
OR
NAME: sandy belcher
ADDRESS: same as mine
PHONE NUMBER: --------
RELATION TO YOU: fianc้/cousin