... 
.. 
a: 
C 
a. 

Name 

N 

.. 
a: 
C 
a. 

·, 

You are required 
after you are excused. 

by law to complete 

and sign this form, which is not a public 

Answer all questions, 

even if the answer is "none." 

record 
Complete 

and will be destroyed 
answers 

by the court as soon as practicable 
juries. 
of fair and impartial 

help ensure selection 

CONFIDENTIAL 

JUROR QUESTIONNAIRE 

PLEASE PRINT YOUR ANSWERS ON THIS FORM IN BLACK INK AND BRING IT WITH YOU WHEN YOU APPEAR FOR JURY DUTY. 

Name:--------------------------- Sex/Gender Identity:-------- 

YOUR BACKGROUND INFORMATION 

City/State 

Zip Code 

Place of Birth 

Age 

YOU MUST BE A CITIZEN, UNDERSTAND 

ENGLISH, 

AND BE 18 OR OLDER TO SERVE. ARE YOU QUALIFIED? 

0 Yes O No 

EDUCATION: 

Highest 

grade completed 

in school? 

CURRENT OR PAST WORK AND/OR SCHOOL: 
(Please check all that apply) 

D Employed 
D Self-employed 
DAt home 
D Student 

D Unemployed 
D Part-time 
D Retired 
D Other 

Your Job or Occupation 

Current Employer (or Last  Employer if not currently employed) 

Type of Business 

City/State 

HOUSEHOLD: Your 

check one) 
D Single D Married D Domestic 

Status (Please 

Partner D Separated D Divorced D Widowed 

Are you the parent or guardian of 
any adult or minor children?  

D No D Yes: List their  ages 
 

YOUR SPOUSE OR PARTNER 

EDUCATION: 

Highest 

grade he/she completed 

in school? 

-----------------------­

CURRENT OR PAST WORK AND/OR SCHOOL: 
check all that apply to him/her) 
(Please 

DEmployed 
D Self-employed 
DAt home 
DStudent 

D Unemployed 
D Part-time 
D Retired 
D Other 

Type of Business 

Job or Occupation 

Current Employer (or Last Employer if not currently employed) 

City/State 

Age 

Have you or anyone in your household 

YOUR EXPERIENCE 
or family 

WITH THE LAW (Please 
ever had any of the following 

check all that apply) 

experiences 

with the law? D No D Yes 

D Been arrested? 
D Been sued? D Filed a lawsuit?  D Been a witness 
D Been served with a court order? 

with a crime? D Been convicted 

of a crime? 
in a civil/criminal 

D Been a crime victim? 
case? D Been seated on a jury? 
stay-away order, 
order, 

D Sought a court order (restraining 

D Been charged 

injunction, etc.)? 

If "Yes," 

please describe: 

P) .. 
a: 
C 
a. 

Have you or anyone in your household 

or family 

D Law enforcement 
D Corrections/detention 

agency? 

system?  D Other law-related 

employer? 

ever worked for any of the following? 
D Court  system? 

IJ No D Yes 

If "Yes," 

please describe: 

Is there anything 
your ability 

else in your background,  experience, 
juror? D No D Yes 

employment, 

to be a fair and impartial 

training, 

education, 

knowledge, 

or beliefs 

that might affect 

If "Yes," 

please describe: 

JUROR'S DECLARATION: 
that a willful 
upon conviction. 

misrepresentation 

or omission 

I certify 

that the information 
of a material 

I have supplied 
fact on this form is a crime, 

on this form is true and complete 

which may be punished 

to the best of my knowledge. 
not more than $2,000 

by a fine of 

I understand 

Signature 

(Do Not Print) 

Date