Juror Qualification Questionnaire

2. First Name*
3. Middle Name*
4. Last Name*
6. Date of Birth*
7. Cell Phone Number*
8. Home/Work Phone Number
10. Address1*
12. Address2
14. City*
15. State*
16. Zip Code*
18. In what county do you live?*
19. Round trip miles from home to court*
20. Email Address*
22. What is your occupation?*
24. What other occupations have you had in the last 10 years?*
26. Have you ever held office in any state, county, or municipality, or have you ever been a law enforcement officer?*

    1. Yes
    2. No
27. If yes, please specify
29. Marital Status*

    1. Single
    2. Married
    3. Widowed

    1. Separated
    2. Divorced
30. What was the last grade you completed in school, or degree received?*
32. Name of Spouse*
33. Spouse's Occupation*
35. Number of children living at home
36. Do you drive?*

    1. Yes
    2. No
37. Check if you are:

    1. Tenant
    2. Landlord
    3. Property Owner
39. Have you, a family member, or a close friend ever been involved in a serious traffic accident?*

    1. Yes
    2. No
40. Who was injured?*

    1. Yourself
    2. Family member(s)
    3. Other(s)
    4. No one
41. Was alcohol involved?*

    1. Yes
    2. No
43. Have you ever been a victim, witness, plaintiff, or defendant in a criminal or civil suit?*

    1. Yes
    2. No
44. If yes, please explain
46. Have you ever been convicted of a crime?*

    1. Yes
    2. No
47. If yes, what?
49. Are there any special accommodations the court needs to make to assist you in serving as a juror?*

    1. Yes
    2. No
50. If yes, please explain the accommodations that would be necessary.
52. Are you a United States citizen?*

    1. Yes
    2. No
53. Do you understand English?*

    1. Yes
    2. No
55. Do you speak English?*

    1. Yes
    2. No
56. If no, please explain what language(s) you speak:
58. Are you physically and mentally able to carry out the functions of a juror?*

    1. Yes
    2. No
59. If no, please explain why
61. The law states that if you are 70 years of age or older you do not have to serve on jury duty unless you want to. If you are 70 years of age or older, do you want to serve on jury duty?*

    1. Yes
    2. No
62. Have you been paid as a juror during the past 12 months?*

    1. Yes
    2. No
63. If yes, where and when?
65. Have you ever been convicted of a felony?*

    1. Yes
    2. No

    A felony means a violation of a penal law of this state, another state, or the United States for which the offender, upon conviction, may be punished by death or by imprisonment for more than 1 year, or an offense expressly designated by law to be a felony.
66. If yes, In what state and when?
68. I declare that the statements above are true to the best of my information, knowledge, and belief.*

    Signature

69. Date*
Leave This Blank:


71. 1. Receive an email copy of this form.
72. Email address

    This field is not part of the form submission.

73. Submit

* indicates a required field