Juror Qualification Questionnaire

2. Last Name*
3. First Name*
4. Middle Initial*
6. Indicate city, township, or village in which you live*
8. What is your occupation?*
10. What other occupations have you had in the last 10 years?*
12. Have you ever held office in any state, county, or municipality, or have you ever been a law enforcement officer?*

    1. Yes
    2. No
13. If yes, please specify
15. Marital Status*

    1. Single
    2. Married
    3. Widowed

    1. Separated
    2. Divorced
16. What was the last grade you completed in school, or degree received?*
18. Name of Spouse*
19. Spouse's Occupation*
21. Number of children living at home
22. Check if you are:

    1. Tenant
    2. Landlord
    3. Property Owner
23. Do you drive?*

    1. Yes
    2. No
25. Have you, a family member, or a close friend ever been involved in a serious traffic accident?*

    1. Yes
    2. No
26. Was alcohol involved?*

    1. Yes
    2. No
27. Who was injured?*

    1. Yourself
    2. Family member(s)
    3. Other(s)
    4. No one
29. Have you ever been a victim, witness, plaintiff, or defendant in a criminal or civil suit?*

    1. Yes
    2. No
30. If yes, please explain
32. Have you ever been convicted of a crime?*

    1. Yes
    2. No
33. If yes, what?
35. Are there any special accommodations the court needs to make to assist you in serving as a juror?*

    1. Yes
    2. No
36. If yes, please explain the accommodations that would be necessary.
38. I declare that the statements above are true to the best of my information, knowledge, and belief.*

    Signature

39. Date*
Leave This Blank:


41. 1. Receive an email copy of this form.
42. Email address

    This field is not part of the form submission.

43. Submit

* indicates a required field