On-Line Jury Qualification Questionnaire

SECTION A -- Personal Information

Please provide information in the spaces provided below.

1. What is your name?
   
   Last Name
   First Name
   Middle Name
   Lineage (e.g., Jr., Sr., II, III)
   
2. What is your birth date?

3. Are you a resident of Liberty County?
   
   No Yes
   
   If not a resident of Liberty County, please specify the county and state where you reside:
   
   
4. What is your mailing address?
   

   Street/P.O. Box
   City
   State
   Zip Code

5. What is your race? (Information required by law)
   
   White (Caucasian)Black (Afro-American)Other  If race is Other, please state.

6. Are you Hispanic/Latino?

No Yes

6. What is your gender?

MaleFemale

7. What is your phone number(s):

 (Home)
 (Work)

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SECTION B -- Juror Exemptions

The following questions regard information required by Georgia law for every juror. Please answer each question.

1. Have you ever been convicted of a felony (serious criminal offense)?
   
   Yes
   No

2. If convicted of a felony, when and where?
   
   1990-1996 1980-1989 1970-1979 1960-1969 1950-1959 Pre 1959 Not applicable, never convicted Conviction year Where convicted (state/county)
   
3. If convicted of a felony, were your civil rights ever restored?
   
   Yes
   No
   
   

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SECTION C -- Special Circumstances

The following questions concern circumstances that may affect your jury service.

1. Check the appropriate block, if applicable?

   I am on active duty status in the United States armed forces.
   I am the spouse of a person on active duty in the United States 
   	armed forces.
   I am not a legal resident of Liberty County and/or the United States.
   I have a physical or mental disability that may impair my ability 
   	to serve as a juror. I can obtain an affidavit from a doctor/psychiatrist detailing
   	my disability. 
   I do not plan on residing in Liberty County more than two years.
   I have a child(ren) under the age of six (6) for whom I provide sole and exclusive care and 
   	no one else is available to provide care.
   Serving on jury duty will cause severe financial hardship for my family or me.
   I do not speak and/or understand the English language well enough to serve as a juror.

2. Please enter any additional comments concerning any of the questions above or this survey.
   
   
   
   

4. What is your E-Mail address?
   
    

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FORM SUBMISSION

Thank you for taking the time to answer the questions in this Jury Qualification Questionnaire.

To submit your responses, click below on the Submit Form button.

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