Form Center

Page 1

Jury Badge Number:
Number is located under barcode.
GENERAL INFORMATION
Please Complete:
1. Check here if address correction is needed
Name:*
Mailing Address:*
City:*
Your Physical Address (if different than mailing address):
Type "Same" if physical address is the same as the mailing address. Otherwise, enter full physical address above including City, State and Zip Code.
Age:*
Date of Birth:*
It is very important that you list where you can be contacted during the day.
Home / Cell Phone:*
Work Phone:
Email:
Marital Status:*
1. Married
2. Single
1. Divorced
2. Widowed
Employment:*
1. Employed
2. Self-Employed
1. Unemployed
2. Retired
Occupation:
Employer:
Spouse's Name:
Please indicate gender:
1. Male
1. Female
Are you of Hispanic or Latino Ethnicity?
1. Yes
1. No
Please indicate race:
1. Black/African American
2. White
1. Native Hawaiian/Pacific Islander
2. American Indian/Alaska Native
1. Asian
2. Other
These answers are required solely to avoid discrimination in juror selection and have absolutely no bearing on qualifications for jury service. By answering these questions, you help the court monitor the juror selection process so that discrimination does not occur. In this way the court can fulfill its legal obligation to provide jurors who are randomly selected from a fair cross section of this community.
Continue

DISABILITIES
NOTE: Access to jury service is available to all individuals with a disability as required by the Disabilities Act of 1990. If you are a person with a disability and require special accommodations, please indicate requirements below:
Disabilities and Requirements
I hereby delcare under penalty or perjury the foregoing is true and correct.
Please enter today's date:*
IMPORTANT: YOU MUST SIGN THIS ONLINE FORM BEFORE CLICKING THE SUBMIT BUTTON. Please check all answers before signing the document. Once you have added your signature, please be sure to click on the SUBMIT button below to submit your information. The CAPTCHA helps us block spamming machines from posting unwanted information. I hereby declare under penalty or perjury the foregoing is true and correct. Type your initials below. Then sign in the "Electronic Signature" box (you can use your mouse).*
By checking the "I agree" box, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.*
1. I agree
Electronic Signature*
Please type your name.

Leave This Blank: