Juror Qualification Questionnaire
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2You are hereby summoned to come before the CIRCUIT COURT of Marion County, (Division I, third floor), at the court-
house thereof at 9:00 AM on June 26, and June 27, 2007 to serve as a Petit Juror.
Witness Barbara A. Core, Clerk of the Circuit Court of Marion County, at the courthouse thereof, Fairmont, West Virginia,
this 28th day of April, 2007, in the 144th year of the State.
THE ATTACHED QUESTIONNAIRE MUST BE FILLED OUT IN ITS ENTIRETY AND RETURNED TO THE
CLERK’S OFFICE BY MAY 14, 2007. FAILURE TO DO SO IS IN VIOLATION OF WEST VIRGINIA CODE 52-1-5a.
If you have any questions regarding the nature of this summons, please call the office of the Circuit Clerk during the hours of
8:30 AM to 4:30 PM Monday through Friday at 367-5382. Please be sure to call the juror telephone number the night before to make
sure that you are still to report on JUNE 26, 2007. The telephone number to call is 366-7100. CALL AFTER 5:00 P.M. If the juror
telephone number is unavailable all 367-5382.
Thank you for your service as a Petit Juror in the 16th Judicial Circuit.
CUT AND DETACH HERE
JUROR QUALIFICATION QUESTIONNAIRE
NAME:
First
Middle
Last
RESIDENCE ADDRESS:
Street or Route and Box Number
City
State
Zip
MAILING ADDRESS: (if different from above)
Street or Route and Box Number
Round trip
Mileage
City
State
Zip
TELEPHONE NUMBER: Home
Business:
DATE OF BIRTH
AGE:
IF AGE 70 OR OLDER, you are NOT disqualified from jury service, but you will be
excused from serving upon your request. Place an “X” in the yes box if you wish to
YES
NO
be excused; place an “X” in the NO box if you wish to serve.
(For questions 1 through 8, place an “X” in the appropriate box)
1. Are you a citizen of the United States?
YES
NO
2. Are you a resident of the county from which you received this questionnaire?
YES
NO
3. Are you at least 18 years old?
YES
NO
4. Are you able to speak, read and understand the English language?
YES
NO
5. Have you served and been compensated as a petit juror, grand juror,
YES
NO
Or magistrate court juror within the past 2 years?
6. Do you have any physical or mental disability which would seriously
YES
NO
impair your ability to serve as a juror?
7. Have you lost the right to vote because of a criminal conviction?
YES
NO
8.
Have you ever been convicted of perjury, false swearing or other infamous
YES
NO
Crime? (Do not count misdemeanor traffic offenses)
9.
SEX
Male
Female 10. MARITAL STATUS:
Married
Single
Divorced
Widow
11. SPOUSE’S NAME:
12. NO. OF CHILDREN:
AGES:
13. RACE/ETHNICITY:
Black
Hispanic
White
Oriental
Other
NOTE: West Virginia law requires you to identify yourself by race to ensure there will be no discrimination in jury selection.
The later-enacted statutes guarantee that jury selection will be entirely at random. This selection is included only to satisfy
Statutory provisions.
14. OCCUPATION:
15. EMPLOYER:
16. SPOUSE’S OCCUPATION:
17. SPOUSE’S EMPLOYER:
18. EDUCATION:
Less than H.S.
H.S. or Equivalent
College
Vocational
Post-Graduate
This mailing serves as it’s own envelope.
Fold on line one and two with Circuit Clerk mailing address showing, use tape to seal and mail.
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