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District Court Juror Questionnaire

Collect the personal and eligibility details needed to speed up juror selection for court proceedings.

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Page 1

Case Number

Juror's Name*

First Name

Last Name

Address*

Street Address

City

State / Province

ZIP / Postal Code

County of Residence*

Phone Number*

Email*

Juror's Number*

Date Listed for Appearance on Jury Summons*

Page 2

Are you a U.S. Citizen?*

Yes No

Gender*

Male Female Prefer not to say

Race (required by Texas Law)*

White Black or African American Hispanic or Latino Asian Native American Other

Age*

Date of Birth*

Your Occupation*

If you indicated you are retired, what occupation are you retired from?*

Your Employer*

How long with Employer?*

Spouse's Name

Spouse's Occupation

Spouse's Employer

How long with Employer?

Current Marital Status?*

Single Married Divorced Widowed

Number of Children*

Age of Youngest Child

Age of Oldest Child

Please check the highest level of education you have completed?*

High School Some College Bachelor's Degree Graduate Degree

Page 3

List of Possible Exemptions:*

Age 65 or Older Primary Caregiver Active Military Duty Full-Time Student Other

Select any of the following disqualifications that may apply:*

Not a U.S. Citizen Felony Conviction Under Legal Age Not a County Resident Other

Upload supporting documents here

Max 10 MB per file

Page 4

Signature*

Sign here

Date Signed*

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