JURY QUESTIONNAIRE

Instructions to Jurors

You have been selected as a prospective juror. It will aid the court and help shorten the trial of cases if you will answer the questions on this form and return it in the enclosed self-addressed stamped envelope within the next 2 days. Please complete the form in blue or black ink and write as dark and legibly as you can.

1. Name (print) _____________________________________

(first) (middle) (last)

2. Residence address ____________________________________

3. Years of residence: In Florida _____________________________

In this county _________________________________________

4. Former residence _________________________________

5. Marital status: (married, single, divorced, widow, or widower) ________________________

6. State the highest level of education you completed

_____ Less than high school

_____ Some college

_____ High school

_____ Associate degree

_____ Vocational/Technical school

_____ College degree

_____ Post graduate degree

7. Your occupation and employer ____________________________

8. If you are not now employed, give your last occupation and employer __________________

9. If married, name and occupation of husband or wife _______________________

10. Have you served as a juror before? _________________________

11. Have you or any member of your immediate family been a party to any lawsuit? ___________________________

If so, when and in what court? ______________________

12. Are you either a close friend of or related to any law enforcement officer? ______________________________

13. Has a claim for personal injuries ever been made against you or any member of your family? _____________________________

14. Have you or any member of your family ever made any claim for personal injuries? _____________

___________________________

Juror’s Signature.