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THE PRESIDING JUDGE REQUEST THAT YOU ANSWER TO THE BEST OF YOUR KNOWLEDGE THE FOLLOWING QUESTIONS AND RETURN ALONG WITH THE JUROR QUESTIONNAIRE CARD (FORM) 1. 2. 3. 4. NAME DATE OF BIRTH
ADDRESS


TELEPHONE NUMBERS (a) Home Telephone Number (b) Business Telephone Number (c) Spouse's Business Telephone Number (d) Emergency Telephone Number PLACE OF BIRTH PLEASE NAME THE SCHOOLS YOU HAVE ATTENDED AND THE GRADE OR LEVEL COMPLETED (a) Grade School (b) Junior High High School (d) College (e) Vocational or Trade School (f) Professional School (g) Graduate Schools (h) Degrees or diplomas you hold HOW LONG HAVE YOU LIVED IN COUNTY? Yes / No No

5. 6.

7. 8. 9. 10. 11. 12. 13.

HAVE YOU EVER LIVED OUTSIDE THE SOUTHEASTERN U.S.? HAVE YOU EVER BEEN IN THE MILITARY SERVICE? PRESENT OCCUPATION WHERE ARE YOU EMPLOYED
LENGTH OF TIME WITH PRESENT EMPLOYER JOB TITLE AND DUTIES (please be specific about you duties) Yes /

SCCA/219 (5/88)


14. 15.

YOUR OCCUPATION BEFORE PRESENT EMPLOYMENT
HAVE YOU EVER WORKED FOR ANY LAW ENFORCEMENT AGENCY, PRISON, JAIL, OR CORRECTIONAL INSTITUTE? Yes / No IF YES WHERE?

16. HAS A MEMBER OF YOUR FAMILY EVER WORKED FOR ANY LAW ENFORCEMENT AGENCY, PRISON, JAIL OR CORRECTIONAL INSTITUTE? Yes / No IF YES, WHERE? 17. MARTIAL STATUS: MARRIED - NUMBER OF YEARS NEVER MARRIED SEPARATED DIVORCED WIDOWED

18. 19. 20. 21.

IF MARRIED, SPOUSE'S NAME SPOUSE'S OCCUPATION SPOUSE'S EDUCATION LEVEL NUMBER OF CHILDREN AND THEIR AGES GIRLS BOYS
HAVE YOU EVER BEEN A WITNESS TO A CRIMINAL CASE? Yes / No Yes / No No

22. 23. 24. 25. 26. 27.

HAVE YOU PREVIOUSLY SERVED ON A JURY IN A CRIMINAL CASE? HAVE YOU PREVIOUSLY SERVED ON A JURY IN A CIVIL CASE? HAVE YOU EVER SERVED ON A GRAND JURY? Yes / No Yes /

WHAT CHURCH (NAME AND DENOMINATION) DO YOU ATTEND? WHAT SOCIAL, CIVIC, FRATERNAL OR CHARITABLE CLUBS AND ORGANIZATIONS DO YOU BELONG TO?

Yes /

No

Date



Juror Signature

SCCA/219 (5/88)