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Juror Questionnaire Form
Date to appear:
Summons Number:
Juror ID:
First Name:
Middle Name:
Last Name:
Street Address:
City:
State:
Zip Code:
Are you a U.S. Citizen?
Yes
No
How long have you lived in this county?
Home Phone:
Cell Phone:
Business Phone:
Place of Birth:
Age:
Marital Status:
Married
Widow(er)
Single
Separated
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?
Yes
No
If Yes, when and in what court?
Spouse/Partner's employer:
Has a claim of personal injury ever been made against you?
Yes
No
Are you related by blood or marriage to any person in Law enforcement?
Yes
No
Have you ever served as a juror?
Yes
No
If yes, what type of case?
Criminal
Civil
Both
Have you ever been a victim of a crime?
Yes
No
If Yes, when and what type of crime?
Name of Insurance Carriers:
Auto Insurance Carrier:
Homeowner's Insurance Carrier:
Health Insurance Carrier: