PLEASE PRINT CLEARLY 1. Last name First name Middle initial2. Indicate city, township, or village in which you live. City � Township � Village � of: 3. What is your occupation?4. What other occupations have you had in the last 10 years?5.Have you ever held office in any state, county, or municipality, or have you ever been a law enforcement officer? Yes � No � If yes, please specify. 6. What was the last grade you completed in school, or degree received? 7. Marital status � Single � Married Widowed � Separated Divorced8. Name of spouse9. Spouse222s occupation10. Number of children living at home 11. Check if you are � Tenant Property owner � Landlord12. Do you drive? Yes � No 13. a. Have you, a family member, or a close friend ever been in a serious traffic accident? � Yes � No b. Was alcohol involved? Yes � Noc. Who was injured? Yourself � Family member(s) � Other(s) � No one 14. Have you ever been a victim, witness, plaintiff, or defendant in a criminal or civil suit? � Yes � No If yes, explain? 15. Have you ever been convicted of a crime? � Yes � No If yes, what? 16. Are there any special accommodations the court needs to make to assist you in serving as a juror? � Yes � No If yes, please explain the accommodations that would be necessary. Date � Signature American LegalNet, Inc. www.FormsWorkFlow.com