Juror Questionnaire Form

Date to appear:
Summons Number:
Juror ID:
First Name:
Middle Name:
Last Name:
Street Address:
Zip Code:
Are you a U.S. Citizen?
How long have you lived in this county?
Home Phone:

Cell Phone:

Business Phone:
Place of Birth: Age:
Marital Status:

Name of Spouse/Partner:

Age of Spouse/Partner:

Number of children:
What is your type of work? Arrest powers?

Number of years worked at current employer?

What is your spouse/partner's type of work?

Number of years spouse/partner worked at current employer?

Your present employer:

Have you or a member of your immediate family been a party to a law suit?

If Yes, when and in what court?

Spouse/Partner's employer:

Has a claim of personal injury ever been made against you?

Are you related by blood or marriage to any person in Law enforcement?

Have you ever served as a juror?
If yes, what type of case?
Have you ever been a victim of a crime?

If Yes, when and what type of crime?

Name of Insurance Carriers:
Auto Insurance Carrier:
Homeowner's Insurance Carrier:
Health Insurance Carrier: