QUALIFICATION FORM
Last Name__________________________ First Name__________________________ Mid. Initial_____
Address_______________________________ Apt______ City__________________ ZIP____________
Phone: Home ________________________________ Business ________________________________
1.	Are you a citizen of the United States?	YES [ ]	NO [ ]
2.	Are you a resident of Owyhee County?	YES [ ]	NO [ ]
3.	Are you able to read, speak and understand the English language?	YES [ ]	NO [ ]
4.	HAVE YOU BEEN CONVICTED OF A FELONY AND ARE YOU ON PROBATION OR PAROLE?	YES [ ]	NO [ ]
5.	If you have served or attended court for jury services within the past 24 months, you may be excused by stating: When ___________________________ Where __________________________________________
6.	If you are 70 years of age or older, you may be excused by signing on this line. _________________________________________________________________________________
A WRITTEN EXPLANATION MUST BE ATTACHED FOR ANY ITEM CHECKED BELOW AND RECEIVED 7 DAYS PRIOR TO THE TERM OF SERVICE.
[ ]	REQUEST FOR EXCUSE: If you have a physical or mental disability which would affect your ability to serve on a jury, submit a written statement supported by a doctor's certificate.
[ ]	REQUEST FOR POSTPONEMENT: State the month you are available for jury service within the next 3 months: _______________________________
The responses to the questions on this Qualification Form are true to the best of my knowledge. I acknowledge that a wilful misrepresentation of a material fact may be punishable by a fine of not more than three hundred dollars ($300) or by imprisonment in the county jail for not more than sixty (60) days, or both. Date: ___________________________ Signature___________________________________________
PROSPECTIVE JUROR QUESTIONNAIRE
1.	Name ________________________________________________________ Sex ____ Age_______
2.	Years of Residency in Idaho __________ in Owyhee County ___________
3.	Prior Place of Residence - City _________________________________ State _________________
4.	Marital Status: Married [ ] Single [ ] Divorced [ ] Separated [ ] Widow [ ] Widower [ ]
5.	Number of Children ________ Ages ___________________________________________________
6.	Your Occupation ____________________________ Employer ______________________________
7.	Spouse's Occupation _________________________ Employer _____________________________
8.	Have you or any member of your immediate family been a party to a lawsuit? If so, type_____________________ what court__________________________	YES [ ]	NO [ ]
9.	Have you ever been a defendant in a criminal action other than a traffic violation? If so, when____________________ what court_________________________	YES [ ]	NO [ ]
10.	Has a lawsuit for bodily injury ever been made against you?	YES [ ]	NO [ ]
11.	Have you ever filed a lawsuit for bodily injury?	YES [ ]	NO [ ]
12.	Do you drive an automobile?	YES [ ]	NO [ ]
13.	Are you related to or a close friend of any law enforcement officer?	YES [ ]	NO [ ]
14.	Have you served as a juror prior to this term?	YES [ ]	NO [ ]
ONE WAY MILES TO COURTHOUSE _________
Signature_______________________________________________ Juror Reporting No. ____________