JUROR QUESTIONNAIRE

PLEASE CONFIRM YOUR ANSWERS TO EACH QUESTION. IF ALL ANSWERS ARE TRUE AND CORRECT TO THE BEST OF YOUR KNOWLEDGE AND BELIEF, CLICK THE SUBMIT BUTTON TO COMPLETE ENTRY OF YOUR QUESTIONNAIRE. IF YOU NEED TO MAKE ANY CHANGES TO YOUR RESPONSES, PLEASE CLICK THE BACK TO QUESTIONNAIRE ENTRY BUTTON AT THE END OF THIS FORM.

SECTION A
QUALIFICATIONS

1. CITIZEN NAMED ON QUESTIONNAIRE DECEASED?

2. ARE YOU A CITIZEN OF THE UNITED STATES?

HAVE YOU LIVED IN EAST BATON ROUGE PARISH FOR THE LAST YEAR?



3. ARE YOU AT LEAST 18 YEARS OF AGE?


4. DO YOU READ, WRITE AND SPEAK THE ENGLISH LANGUAGE?


5. ARE YOU UNDER INTERDICTION OR ARE YOU INCAPABLE OF SERVICE BECAUSE OF ANY MENTAL OR PHYSICAL INFIRMITY?



IF YES, PLEASE EXPLAIN:


6. ARE YOU 70 YEARS OF AGE OR OLDER AND DO NOT WISH TO SERVE?

CONFIDENTIAL
INFORMATION


1. NAME:    AGE:

    ADDRESS:

2. IN ORDER TO COMPLY WITH LOUISIANA LAW, AND IN ORDER TO ENSURE THAT PERSONS ARE NOT BEING EXCUSED FROM JURY SERVICE ON THE BASIS OF RACE, SEC, OR AGE, YOU ARE REQUIRED TO FURNISH THE FOLLOWING INFORMATION:

RACE:   SEX:

3. PLACE OF BIRTH (CITY AND STATE):     NUMBER OF YEARS YOU HAVE LIVED IN EAST BATON ROUGE PARISH:

4. PRESENT OCCUPATION (PLEASE DESCRIBE WHAT YOU DO, YOUR JOB RESPONSIBILITIES, YOUR JOB TITLE, WHETHER YOU SUPERVISE OTHER EMPLOYEES, THE NAME OF YOUR EMPLOYER, THE LENGTH OF EMPLOYMENT AND YOUR JOB SKILLS AND TRAINING):


5. ARMED SERVICES EXPERIENCE, IF ANY - DATE AND BRANCH OF SERVICE, RANK, WHERE STATIONED, DUTIES PERFORMED, SPECIAL TRAINING, TYPE OF DISCHARGE:


6. NUMBER OF YEARS OF EDUCATION: GRADE SCHOOL:    COLLEGE:

7. HAVE YOU EVER BEEN THE VICTIM OF A CRIME?

IF YES, STATE WHAT CRIME, WHEN IT OCCURRED, AND THE RELATIONSHIP OF THE VICTIM TO YOU:

8. HAS ANY CLOSE FRIEND OR RELATIVE OF YOURS EVER BEEN THE VICTIM OF A CRIME?

IF YES, STATE WHAT CRIME, WHEN IT OCCURRED, AND THE RELATIONSHIP OF THE VICTIM TO YOU:


9. WHAT NEWSPAPERS AND MAGAZINES DO YOU READ?



10. WHAT TYPE OF TV PROGRAMS DO YOU WATCH THE MOST?


11. DO YOU KNOW OF ANY REASON YOU COULD NOT SERVE AS A JUROR AND BE FAIR TO THE STATE AND THE DEFENSE IF YOU ARE SELECTED TO SERVE ON A JURY?

IF YES, PLEASE STATE THE REASON:

12. REMARKS: USE SPACE BELOW TO COMPLETE ANY ANSWERS TO THE QUESTIONNAIRE WHICH REQUIRE MORE INFORMATION. SHOW THE NUMBER(S) OF QUESTIONS OR LETTER(S) TO WHICH YOU ARE FURTHER RESPONDING.



(If questionnaire was completed by someone other than , please state above why it was necessary for you to complete)

13. Home Phone Number:

14. Cell Phone Number:

15. Email:

Email will be used ONLY for notification of status of jurors need to appear.

I declare under penalty of perjury that all answers are true to the best of my knowledge and belief.