THE MUNICIPAL COURT OF CHILLICOTHE, OHIO
26 South Paint Street
Chillicothe, Ohio 45601
614-773-3515
Juror Number__________ CT. # 1
PROSPECTIVE JUROR QUESTIONNAIRE
The purpose of this document: To provide general information
about you that takes much longer if done in court by individual
interview. A single duplicate of this questionnaire is made and
both copies are destroyed after your jury service. We regret
that jury duty should be accompanied by the following
disclosures, but the right to a jury trial is accompanied by the
right to know a certain amount about the jurors. Please bear
with us (and please print or write clearly). Thank you.
1. Name: __________________________________________ Age:______
first initial last
2. Home address: _______________________________, ____________
# street or route years at this
address
_______________________________, (Must be Ross)
City/Post Office County
3. Phone Numbers: Home:________________ Work:_________________
4. Place of Birth:_____________________________________________
City State
5. Years of Residence in Ross County:__________________________
6. Occupation and Employer:____________________________________
____________________________________________________________
(if retired, please write "retired" & list last employer)
7. Marital Status: Married Separated Divorced
(please circle) Single Widow Widower
8. What is the name of your Spouse's Employer:________________
___________________________________________________________
(if retired, please write "retired" & list last employer)
9. Education: 6 7 8 9 10 11 12 13 14 15 16 16+
(please circle number of years of education completed)
10. Please list spouse and children living with you in household:
Name Relationship to You Age Occupation
____________________________________________________________
____________________________________________________________
11. Have you served as a juror before? () Yes () No
If "Yes", when and in what court?
12. Have you been convicted of a crime punishable as a felony
(Defined as any offense punishable by more than one year of
imprisonment and involving "moral turpitude" such as, theft
or forgery) where you have not received a pardon from the
governor of this state? () Yes () No
If "Yes", please give particulars of, date and place:
13. Have you or any member of your immediate family been the
victim of a crime? () Yes () No If "Yes", was it an
() offense of violence or a () Property crime, such as a
theft or breaking & entering? Details Optional:
14. Have you or any member of your family been sued or filed a
suit against another person or corporation? () Yes () No
If "Yes", when and where?
You will probably be asked if a local attorney represented
you or the other party. If so, please list attorney name:
.
15. Are you related or a close friend to any law enforcement
officer or attorney () Yes () No. If "Yes", please
give name(s):
16. Do you have a driver's license and do you drive?
17. Many cases involve alcohol consumption and driving. Do you,
on occasion, partake of alcoholic beverages? () Yes () No
18. Are you personally opposed to the use of alcoholic beverages
by others, for any reason? () Yes () No
19. Are you a member of any organization, the purpose of which
is to oppose the use of alcoholic beverages? () Yes () No
20. Do you own stock in, have any connection with, or any
interest in any casualty insurance company, other than as
the holder of an insurance policy with such company?
() Yes () No If "Yes" please specify
The foregoing is true to best of my knowledge.
Date_____________ Juror's Signature________________________
THANK YOU FOR YOUR CO-OPERATION.