Jury Qualification Questionnaire For Bonner County, Idaho
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1JURY QUALIFICATION QUESTIONNAIRE FOR BONNER COUNTY, IDAHO
COMPLETE AND RETURN THIS FORM WITHIN 10 DAYS TO THE JURY COMMISSIONER IN THE ENCLOSED ENVELOPE
Date of Selection:_____________________
Office Use Only
Reporting Number: ___________________
Code:_______
Date of Birth:_________________
PP:_________
Make name and/or address corrections in this area
Name:
________________________________________
Address:
___________________________________________
___________________________________________
City/State/Zip
1. Are you a citizen of the United States? ………………………………………………. Yes
No
IF YOUR ANSWER IS “NO”, YOU MUST PROVIDE A COPY OF YOUR LEGAL DOCUMENTATION TO SUPPORT THIS STATEMENT.
2. Are you a resident of Bonner County? (If “NO” provide address change above)…. Yes
No
3. Are you able to read, speak and understand the English Language? …………………
Yes
No
4. Have you lost your right to vote due to a felony criminal conviction? ………………….Yes
No
If your answer is yes, are you currently on probation or parole? ……………… Yes
No
5. Within the past 24 months, have you been assigned to jury service in Bonner County? Yes
No
If your answer is yes, do you wish to be excused during this term? ……………. Yes
No
6. Do you have a physical/mental disability that would affect your ability to serve?......... Yes
No
IF YOUR ANSWER IS YES, YOU MUST PROVIDE THE PHYSICIAN’S CERTIFICATE ON THE REVERSE SIDE OF THIS QUALIFICATION FORM.
7. I am over 70 years of age and wish to be permanently excused from jury service……. Yes
No
IF YOU ARE OVER 70, YOU DO NOT HAVE TO PROVIDE A REQUEST FOR A MEDICAL EXEMPTION.
8. Current Physical Address:___________________________________________________________________________
9. Mileage ONE WAY from your residence to the courthouse_______________ (to be used for payment of mileage)
THE ABOVE INFORMATION IS TRUE TO THE BEST OF MY KNOWLEDGE AND I UNDERSTAND THAT ANY WILLFUL MISREPRESENTATION OF
FACT MAY BE PUNISHED AS A MISDEMEANOR.
_________________
________________________________________________
_________________________
Date
Signature
Phone Number
If you are completing this form for the juror please sign here:____________________________________________________
Reason you are completing this form:_________________________________________________________________________
The following information is voluntary. Its purpose is to expedite jury processing in the Courtroom and to save you time at the Courthouse.
1. Years of residence in Idaho: __________ in Bonner County:________ Prior Residence:______________________
2. Age:________
Marital Status (circle): single
married
divorced
separated
widow
widower
3. Number of children:_______
Ages:___________________
Emergency Contact:_____________________________
4. Your Occupation:____________________Employer:_______________________________ Phone:___________________
5. If retired, give last employer:_________________________________________________
6. Spouse’s occupation:_________________Employer:____________________________
Phone:___________________
7. If spouse is retired, give last employer:_____________________________________
8. Have you or any member of your immediate family ever suffered serious bodily injury?
Yes
No
9. Have you ever been a defendant in a criminal action other than a traffic violation?
Yes
No
10. Do you drive an automobile?
Yes
No
11. Are you related to or a close friend of any law enforcement officer?
Yes
No
12. Have you served as a juror prior to this term? If yes, where and when__________________________
Civil
Criminal
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