4-602C. Juror questionnaire.[For use with Rules 1-047, 2-603, 3-603]JUROR QUESTIONNAIRE FORMJuror Badge Number: Please answer all questions, 1-35, and SIGN. The Juror Questionnaire will be provided to theattorneys, parties, and judges in all cases you may be selected to hear as a juror. The answers youprovide will aid in the process of selecting a jury. If you do not understand a question, pleaseplace a question mark (?) next to the question. If you do not have enough room to answer thequestion, please use the space in question 35 or a separate sheet of paper. If there is a questionyou would rather discuss with the judge and attorneys in private, please indicate with an asterisk(*). Thank you for your cooperation. Date of jury service: day month 1.Legal name and former names: 2.Gender: Male Female 3.Date of birth: Birth place (city and state; country if outside the United States): 4.How long have you lived in New Mexico? 5.In which New Mexico county do you live? How long? 6.Which town or city do you live in? Neighborhood? What major intersection is closest to your home? 7.Where else have you lived (city, state, country)? 8.What is your marital status? single married domestic partner separated divorced widowed 9.What is your ethnic background? 10.Do you own or rent your home? own rent American LegalNet, Inc. www.FormsWorkFlow.com 11.Your occupation: (If retired or unemployed please state, and also state your previous occupation.) 12.If employed please state: Name of employer and place of work: Job title and duties: Time worked there: Normal working hours: How many hours per week do you work? 13.Do you have a second job? Yes No 14.What other jobs have you had as an adult? 15.How many years of schooling have you completed? Highest level completed? high school or GED associate trade or vocational school bachelor master Ph.D. M.D. J.D. Major areas of study: 16.Have you served in the military? Yes No Highest rank: 17.Do you belong to or participate in any religious, civic, social, union, professional,fraternal, political, or recreational organizations? Yes No Organization: Office held: 18.Current voter registration: Democrat Republican Not registered No party selected Other, please specify: 19.If you are married or in a domestic partnership, please provide spouse222s/partner222s fullname and occupation: 20.Do you have any children or stepchildren? Yes No How many? ages occupations 21.Have you ever been a witness in a court proceeding? Yes No If yes, what type of case was it? civil criminal What were the circumstances? 22.Have you ever served as a juror? Yes No If yes, year: court or location: case type: If yes, year: court or location: case type: American LegalNet, Inc. www.FormsWorkFlow.com Were you ever the foreperson? Yes No If yes, courts: years: 23.Have you ever had an injury that required hospitalization or extended medical care? Yes No If yes, what was the injury? Did the injury cause you to lose time from work? Yes No If yes, how long? 24.Have you or any member of your family ever filed a civil suit against someone? Yes No If yes, please explain: 25.Have you or any member of your family ever been sued? Yes No If yes, please explain: 26.Have you or an immediate family member ever been an agent, employee, orrepresentative of an insurance company? Yes No If yes, who and relationship to you: 27.Have you or any member of your immediate family been the victim of a crime? Yes No If yes, who was the victim? What crime? When? Was an arrest made? Yes No 28.Have you or an immediate family member been a defendant in a criminal case? Yes No If yes, who and relationship to you? Crime accused of committing? Was there a conviction? Yes No 29.Have you, any family member, or close friend ever been employed by, or volunteered for,any federal, state, or local law enforcement agency; a jail, prison or detention center; or adistrict attorney or other prosecuting attorney222s office? Yes No If yes, who? Relationship to you: Position held: Dates of employment: Name of agency, or attorney and office: 30.Have you or any family member ever worked for any other attorney? Yes No If yes, who? American LegalNet, Inc. www.FormsWorkFlow.com Relationship to you: Position held: Dates of employment: Name of attorney and office: 31.Have you or any family member ever been represented by an attorney or law office? Yes No If yes, name of attorney and office: 32.Do you have a physical disability of which we need to be aware? Yes No If yes, are there any special accommodations, services, or assistance we can provideduring your jury service? Yes No Please explain: 33.Are you presently taking any medication that may affect your ability to serve as a juror? Yes No If yes, please explain: 34.Is there any reason you could not serve as a juror? Yes No (If you arerequesting an excusal or postponement for this reason, you must complete and submit theRequest for Postponement, Excusal, or Exemption Form)If yes, please explain: 35.Use this space for any additional comments: I SWEAR OR AFFIRM THAT THE ABOVE INFORMATION IS TRUE ANDCORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF. Signature of prospective juror Date Signature of preparer, if different than Dateprospective jurorPlease return completed Juror Qualification and Juror Questionnaire forms to the courtlisted on the summons you received.[Approved by Supreme Court Order No. 17-8300-016, effective December 31, 2017.] American LegalNet, Inc. www.FormsWorkFlow.com