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Personal Information:
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Name: SSN:
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Race: Sex: Age: Date of Birth: ___/___/___ Place of Birth:
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Address: Apt. Own Rent, Years there:
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City: County: Zip + 4:
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Phone: Cell Phone:
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Email: Website:
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Social Media: Are you on any of the following sites? Facebook Instagram Twitter YouTube Blog Other
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If you checked ”Blog” or “Other,” what is the site?
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Marital Status: Single, Married, Divorced, Widowed Religion: Political Affiliation:
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Employment:
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Employer: Your title: Years there:
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Nature of work: Your Supervisor:
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Address: Suite:
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City: County: Zip + 4:
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Phone: Cell Phone:
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Email: Website:
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Questionnaire:
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1. Have you ever served on a jury before? What kind of case?
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2. Have you ever sued anyone? What was it for?
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3. Have you ever been sued? What was it for?
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4. Have you ever been arrested and/or convicted of a crime? If so, what?
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5. What is your opinion on [type of current case] ?
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6. What, if anything, have you heard about [current case] ?
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7. What is your opinion of [potential penalties] ?
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8. Do you personally know any of the following people [judge, client, opposing client, opposing counsel] ?
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9. Have you ever been in a situation involving [pertinent tidbit from case] ?
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I certify, to the best of my knowledge, that all information and answers provided above are complete, honest, and correct.
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Signature: Date:___/___/___
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For Office Use Only
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Remarks:
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Document Ctrl #
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Filename:
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