1. Name: * Juror ID # * Group # * Report Week Starting Date: *
        DOB: * Race / Ethnicity: Gender:
2. City of residence: Length of residence:
3. Current Occupation: For how long?
4. Prior Occupation: For how long?
5. List highest level of     education reached: Major and/or degree(s) (if applicable):
6. Marital Status: Number of children:
7. Occupations of adult children:
8. List other adults in your household and their occupations:
9. Have you ever served on a jury before?            

10. Have you or anyone close to you (relative, close friend or colleague, etc.), ever been
a. The victim of or witness to a crime? If so, please describe::
b. Accused of or convicted of a crime? If so, please describe:
c. A party to or testified in a civil lawsuit? If so, please describe:
d. Employed within the legal or court systems (law enforcement, attorney, probation, social services, corrections, etc.) or had any related training or experience? If so, please describe:
11. Do you know of any reason why you would not be able to be a fair and impartial juror?
12. Please provide any additional information below:
13. Please describe your reason if you wish to file a Hardship Request.
14. I declare under penalty of perjury that the foregoing is true and correct to the best of my knowledge. *
By submitting this form all answers will be sent to the Jury Services Unit. If you need to correct this form, you must complete a new form, in its entirety and submit.

Confidentiality Notice: Questionnaires will be destroyed if the prospective juror is not assigned to a jury trial department.