Free Notice of Filing Proposed Pretrial Order - District Court of Arizona - Arizona

Exhibit "J"
Case 2:04-cv—00384—ROS Document 528-11 Filed 08/31/2007 Page 1 of 3

Defendant Proposed Juror Questionnaire
Case 2:04-cv—00384—ROS Document 528-11 Filed 08/31/2007 Page 2 of 3

CONFIDENTIAL JUROR QUESTIONNAIRE
You are required by law to complete and sign this form, which is not a public record and will be destroyed by the court as soon as practicable
after you are excused. Answer all questions, even if the answer is "none." Complete answers help ensure selection of fair and impartial juries.
PLEASE PRINT YOUR ANSWERS ON THIS FORM IN BLACK INK AND BRING IT WITH YOU WHEN YOU APPEAR FOR JURY DUTY
YOU MUST BE A CITIZEN, UNDERSTAND ENGLISH, AND BE 18 OR OLDER TO SERVE. ABE [QU QUALIFIED? CI Yes Cl No

YOUR BACKGROUND INFORMATION
I CI Female Cl Male
Name
City/State Zip Code Place of Birth Age
EDUCATION: Highest grade completed in school?
. F -
CURRENT OR PAST WORK AND/OR SCHOOL: -
I" (P/ease check all that apply)
I Current Employer (or Last Employer if not currently employed)
< D Employed CI Unemployed y
L . El Self-employed L] Part-time Typg gf Business ' Té "` "(;jty/5taj`€` ;
Cl At home EI Retired
D Student U Other Your Job or Occupation
.. HOUSEHOLD: Your Status (Please check one)
El Single El Married Cl Domestic Partner EI Separated El Divorced EI Widowed ’
A Are you a parent or guardian of any children? CI No E1 Yes: Please list their ages

YOUR SPOUSE OR PARTNER
I- Name Age
N I EDUCATION: Highest grade he/she completed in school?
I-' CURRENT OR PAST WORK AND/OR SCHOOL:
E (Please check all that apply to him/hen
` Current Employer (or Last Employer if not currently employed)
- g_ Cl Employed El Unemployed
El Self-employed Cl Part-time p€ of Business V City/SWB
V N EI At home Cl Retired
Cl Student CI Oth9l’

_, I YOUR EXPERIENCE WITH THE LAW (P/ease check all that apply) i
‘ [ Have you or anyone in your household or family ever had any of the_foIIowing experiences with the law? Cl No El Yes
y : I EI Been arrested? CI Been charged with a crime? El Been convicted of a crime? CI Been a crime victim?
-»‘_/ CI Been sued? El Filed a lawsuit? C1 Been a witness in a civil/criminal case? EI Been seated on a jury?
‘ CI Been served with a court order? El Sought a court order (restraining order stay-away ordel; injunction, etc.)?
I _`,_ , If "Yes," please describe: ‘
Fl .
Z jg Have you or anyone in your household or family ever worked for any of the following? El No EI Yes
I · El Law enforcement agency? EI Court system?
W · Cl Corrections/detention system? El Other law-related employer? I
ll ; lf "Yes," please describe:
‘)‘, Is there anything else in your background, experience, employment, training, education, knowledge, or beliefs that might affect
all E your ability to be a fair and impartial juror? CI No El Yes `
lf "Yes, " please describe:

JUROR’S DECLARATION: I certify that the information I have supplied on this form is true and complete to the best of my knowledge. I understand
that a willful misrepresentation or omission of a material fact on this form is a crime, which may be punished by a fine of not more than $2,000
upon conviction.
Si nature (Do Not Print) _ Dale
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Case 2:04-cv-00384-ROS

Document 528-11

Filed 08/31/2007

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Case 2:04-cv-00384-ROS

Document 528-11

Filed 08/31/2007

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Case 2:04-cv-00384-ROS

Document 528-11

Filed 08/31/2007

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