Juror Questionnaire Template
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Juror Questionnaire
Juror Information
First Name
Last Name
Middle Initial
Maiden Name
Date of Birth
Age
Location of Birth
Sex
Race
Mailing Address
County
Home Phone Number
Cell Phone Number
Work Number
Marital Status
Spouse Name
Occupation
Occupation
Employer
Government/Official Jobs Held
Years at Job
Years Lived in County
Years Lived in State
Miles from Home to Court
Miles from Work to Court
Please Check All the Boxes That Apply
I am a United States Citizen
Yes
No
Years of Citizenship:
I am a resident of the county that summoned me
Yes
No
If no, name county:
I can understand and read the English language
Yes
No
I am a convicted felon
Yes
No
Crime Committed:
Location of Crime:
Date:
I am presently under indictment
Yes
No
I am over eighteen years of age
Yes
No
I am currently a witness, defendant or plaintiff in a criminal case
Yes
No
I have served as a juror in the past 12 months
Yes
No
Location and Court:
Dates Served:
I hereby swear that all information listed above is factually true to the best of my knowledge.
Signature:
Date:
For Clerical Use Only
Juror Is:
Qualified For Duty
Disqualified for Duty due to:
Excused due to:
Postponed Until:
Signature:
Date:
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Parent category: Life