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Juror Questionnaire Form
Date to appear:
Summons Number:
Summons Number is required!
Juror ID:
Juror ID is required!
First Name:
First Name is required!
Middle Name:
Last Name:
Last Name is required!
Street Address:
Street Address is required!
City:
City is required!
State:
State is required!
Zip Code:
Zip code is required!
EXAMPLE: xxxxx or xxxxx-xxxx
Are you a U.S. Citizen?
Yes
No
U.S. Citizen is required!
How long have you lived in this county?
How long lived in county is required!
Home Phone:
Cell Phone:
EXAMPLE: (xxx) xxx-xxxx
EXAMPLE: (xxx) xxx-xxxx
Business Phone:
EXAMPLE: (xxx) xxx-xxxx
Place of Birth:
Place of Birth is required!
Age:
Age is required!
Must be a numeric value greater than 0!
Marital Status:
Married
Widow(er)
Single
Separated
Marital Status is required!
Name of Spouse/Partner:
Age of Spouse/Partner:
Must be a numeric value greater than 0!
Number of children:
Number of Children is required!
Must be a numeric value greater than 0!
What is your type of work? Arrest powers?
Type of work/Arrest Powers is required!
Number of years worked at current employer?
Number years worked at current employer is required!
Must be a numeric value greater than 0!
What is your spouse/partner's type of work?
Number of years spouse/partner worked at current employer?
Must be a numeric value greater than 0!
Your present employer:
Present Employer is required!
Have you or a member of your immediate family been a party to a law suit?
Yes
No
Party to Lawsuit is required!
If Yes, when and in what court?
Spouse/Partner's employer:
Has a claim of personal injury ever been made against you?
Yes
No
Personal Injury Claim is required!
Are you related by blood or marriage to any person in Law enforcement?
Yes
No
Related to Law Enforcement is required!
Have you ever served as a juror?
Served on a juror is required!
Yes
No
If yes, what type of case?
Criminal
Civil
Both
Have you ever been a victim of a crime?
Yes
No
Victim of crime is required!
If Yes, when and what type of crime?
Name of Insurance Carriers:
Auto Insurance Carrier:
Auto Insurance is required!
Homeowner's Insurance Carrier:
Homeowner's Insurance is required!
Health Insurance Carrier:
Health Insurance is required!