Supervisorial District: (for staff use only) Superior Court of California County of Santa Clara 2019-2020 CIVIL GRAND JURY APPLICATION AND NOMINATION FORM PLEASE COMPLETE THIS APPLICATION ONLINE. FOR DOWNLOADED APPLICATIONS, PLEASE PRINT IN BLACK INK OR TYPE. Mr. Mrs. Ms. Dr. 1. Name: Sex: M F Last First Middle 2. Residence Address: Street City Zip 3. Home Phone: ( ) Cell Phone: ( ) Fax Number: ( ) E-mail: Date of Birth: / / Place of Birth: Age Range: 18 - 25 26 - 34 35 - 44 45 - 54 55 - 64 65 - 74 75 and over Driver License or State ID Number: Indicate your ethnic derivation by checking one of the following: American Indian or Alaska Native Hispanic/Latino Asian Native Hawaiian or other Pacific Islander Black or African American White Other Race or ethnicity; please state: Decline to answer 4. Student: Yes/No 5. Employment Status: Presently Employed Not Employed Retired If Presently Employed, 6. Occupation: Employer: 7. Business Address: Street City Zip Business Phone: ( ) Please provide DETAILED (PRESENT and/or PAST) employment (10 years or two most recent jobs) and educational background information on separate sheet of paper. American LegalNet, Inc. www.FormsWorkFlow.com Superior Court of California County of Santa Clara Civil Grand Jury Application, 2019-2020 Last Name: 2 8. If you are employed, does your employer understand the nature of the duties of a Grand Juror and will he/she release you to full-time Grand Jury service for the entire period that the jury shall be in session? Yes No If you are currently employed, a written release verification from your employer MUST BE ATTACHE D TO THIS APPLICATION. EMPLOYERS ARE NOT REQUIRED TO PAY WAGES TO CITIZENS SERVING ON THE CIVIL GRAND JURY . 9. Name of Spouse: Pursuant to California Rules of Court, Rule 1.100 and the Americans with Disabilities Act (ADA), the Superior Court of California, County of Santa Clara, does not discriminate against persons with disabilities. 10. Do you require any accommodations for a mental or physical condition (including impaired hearing, eyesight or mobility) to enable you to participate in the application process or as a Grand Juror? (Please explain) 11. Are you a citizen of the United States? Yes No 12. Do you read and understand English? Yes No 13. Are you 18 years or older and will you have been a resident of the State of California and of the County of Santa Clara for at least one year as of June 20, 2019? Yes No 14. Are you a registered voter? Yes No 15. The Political Reform Act (Gov. Code Sections 81000-91014) requires most state and local government officials and employees who make or participate in the decision-making process to publicly disclose their personal assets and income. If you are selected as a Grand Juror, you will be required to complete a Statement of Economic Interest (Form 700). Are you willing to complete the Form 700 ? Yes No American LegalNet, Inc. www.FormsWorkFlow.com Superior Court of California County of Santa Clara Civil Grand Jury Application, 2019-2020 Last Name: 3 16. Are you related to or closely associated with any elected official or public employee? Yes No If yes, please give their name(s) and explain relationship(s): 17. Are you currently serving as an elected public official? Yes No Title: Date term ends: 18. Have you ever been convicted of any of the following? Malfeasance in Office Yes No Felony Yes No Misdemeanor Yes No , please give details below: Please note that a misdemeanor conviction is not an automatic bar to acceptance of application. Each case is considered individually and confidentially. Please provide additional information on a separate sheet if necessary. Offense City/State Date Penalty 19. As a member of any profession or organization or as a holder of any office, have you ever been suspended, disbarred or otherwise disqualified? Yes No 20. Are you contemplating any absence from Santa Clara County in the Fiscal Year 2019-2020, which might interfere with your performance as a Grand Juror? Yes No If yes: Departure Date: Return Date: American LegalNet, Inc. www.FormsWorkFlow.com Superior Court of California County of Santa Clara Civil Grand Jury Application, 2019-2020 Last Name: 4 If selected as one of the finalists, will you be able to attend the Drawing/Impanelment Ceremony on Thursday, June 20, 2019 at 4 PM? Yes No (Attendance is Mandatory) Please Note: Training pursuant to Penal Code 247 914, for the 2019-2020 Civil Grand Jury is tentatively scheduled on June 27, 2019; July 11 and 12, 2019; and July 17, 2019. It is mandatory that each of the persons selected for the 2019-2020 Civil Grand Jury attend these meetings. Will you be able to attend all of the training sessions? Yes No 21. If selected as a Grand Juror, you will be required to swear or to affirm the following obligation: that I will support the Constitution of the United States and the State of California, and all laws made pursuant to and in conformity therewith, will diligently inquire into, and true presentment make, of all public offenses against the people of this state, committed or triable within this county, of which the Grand Jury shall have or can obtain legal evidence. Further, I will not disclose any evidence brought before neither the Grand Jury, nor anything which I or any other Grand Juror may say, or the manner in which I or any other Grand Juror may have voted on any matter before the Grand Jury Do you have any objections to taking such an oath or affirmation? Yes No 22. Will you define and evaluate issues without expressing personal bias? Yes No 23. Are you aware that the Civil Grand Jury is required to publish a final report of issues they have investigated? Yes No 24. Are you willing to investigate county government issues and prepare reports on these issues? Yes No 25. Please outline your knowledge and understanding of the role and function of the Civil Grand Jury and of county government. (Attach additional sheets if necessary) 26. Why do you want to serve on the Civil Grand Jury and what contributions would you hope to make as a member? (Attach additional sheets if necessary) American LegalNet, Inc. www.FormsWorkFlow.com Superior Court of California County of Santa Clara Civil Grand Jury Application, 2019-2020 Last Name: 5 27. Please assist the Court in the evaluation of the Grand Jury recruitment program by indicating from which source you learned about service on the Santa Clara County Civil Grand Jury. Newspaper (which?) Community Organization TV/Radio (which?) Public Gathering Social Media (which?) Government Agency (which?) Referred by Other I am in possession of all my natural faculties, of ordinary intelligence and of sound judgment and fair character. I certify under penalty of perjury, that all of the statements I have made are true, complete and accurate. Executed at , California. City Signature: Dated: For Court Use Only The above candidate is suitable, competent and qualified to serve as a Grand Juror, for the Fiscal Year 2019-2020 under Sections 893 and 896 of the California Penal Code. I have discussed the requirements for Grand Jury service and have ascertained availability for service. Date HON. DEBORAH A. RYAN Presiding Judge of the Superior Court State of California, County of Santa Clara American LegalNet, Inc. www.FormsWorkFlow.com Superior Court of California County of Santa Clara Civil Grand Jury Application, 2019-2020 Last Name: 6 APPLICANT STATEMENT I, , understand that my name may be placed in nomination to be considered for membership on the Civil Grand Jury of Santa Clara County for the Fiscal Year 2019-2020. I understand that the term will be from June 20, 2019 to June 18, 2020. I am aware that such service requires that I be in attendance at least 25 hours per week and frequently more. In this regard, I understand that as a Grand Juror I must be flexible and able to serve some evening and weekend hours as well as working during normal business hours as determined by the 2019-2020 Civil Grand Jury. I declare, pursuant to Penal Code 247 896(a), that I will be available to serve during those required hours. Each member of the Grand Jury shall be allowed a per diem attendance, either at gen