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2. Juror Number*
4. First Name*
5. Last Name*
7. Address1*
9. City*
10. State*
11. Zip*
13. Mailing Address (if different than home)
15. City
16. State
17. Zip
19. Phone Number*
20. Email
21. County of Residence*
23. Gender*
24. Race (required by state law)*
25. Age*
26. Date of Birth*
28. Driver's License Number*
29. Place of Employment*
31. Type of Work
32. Length of Time at Job
34. Employer's Address
36. Military Service?
37. Are you on active duty deployed outside your county of residence?
39. Relationship Status
    -- Select One --MarriedSingleWidowedDivorced
40. Children?
41. Ages
43. Name of Spouse or Nearest Living Relative
44. Relationship
46. Address
48. Spouse's Employer
49. Type of Work
51. Spouse's Employer's Address
53. Do you have any relatives or friends who are peace officers?
    -- Select One --YesNo
55. Have you ever been called for jury service?
    -- Select One --YesNo
56. If yes, Where?
58. Did you serve as juror?
    -- Select One --YesNo
59. If yes, when and where?
61. Criminal Case?
62. Civil Case?
64. Verdict Reached?
65. Verdict Reached?
67. Been party to a lawsuit?
    -- Select One --YesNo
68. As Plaintiff?
69. As Defendant?
71. Served on Grand Jury?
    -- Select One --YesNo
72. Where
73. When
75. Has any accidental bodily injury ever been suffered by you?
    -- Select One --YesNo
77. By a member of your family?
    -- Select One --YesNo
79. Have you ever been interested in the outcome of a criminal case as a defendant, victim, or witness?
    -- Select One --YesNo
81. Where and what?
83. Today's Date
    Today's Date
84. Juror's Signature
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86. 1. Receive an email copy of this form.
87. Email address

    This field is not part of the form submission.

88. Submit

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