_________________________________________________________ _________________________________________________________ (name of authority selecting jury) QUESTIONNAIRE FOR PROSPECTIVE JURORS 1. Name (print) (first) (middle) (last) 2. Residence address (street and number) (city) (zip) 3. Date of birth Sex Occupation 4. Do you understand the English language? __________ (yes) __________ (no) 5. Do you read and write the English language? __________ (yes) __________ (no) 6. Have you ever been convicted of a crime and not restored to your civil rights? __________ __________ (yes) (no) If "yes," state nature of crime, date of conviction, and name of court in which convicted: _____________________________________________________________________________________________ _____________________________________________________________________________________________ 7. Are there any criminal charges pending against you of which you are aware? __________ (yes) __________ (no) If "yes," state nature of charge and name of court in which the case is pending: _____________________________________________________________________________________________ _____________________________________________________________________________________________ 8. Are you a bonded deputy sheriff? __________ (yes) __________ (no) 9. List any official executive office you now hold with the federal, state, or county government: _____________________________________________________________________________________________ American LegalNet, Inc. www.USCourtForms.com 10. Is your hearing good? __________ __________ (yes) (no) 10. Is your hearing good? __________ __________ (yes) (no) (The court may require a medical certificate.) 12. Do you know of any reason why you cannot serve as a juror? __________ (yes) __________ (no) If “yes,” state reason: _____________________________________________________________________________________________ _____________________________________________________________________________________________ 13. MOTHERS AND EXPECTANT MOTHERS ONLY: Florida law provides that expectant mothers and mothers with children under 18 years of age residing with them shall be exempt from jury duty upon their request. Do you want to be exempt under this provision? __________ (yes) __________ (no) If "yes," what are the ages of your children? ______________________________________________________________ __________________________________________________ Signature This is not a summons for jury duty. If your name is later drawn for jury service, you will be summoned by the sheriff by registered mail or in person. American LegalNet, Inc. www.USCourtForms.com