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2. 
3. IN THE DISTRICT COURT OF GEARY COUNTY, KANSAS
   You have been selected to serve as a juror in the District Court of Geary County. Please carefully read and answer the questions on this form. The Juror Questionnaire is not a public record and is only made available to court personnel and the attorneys to the case being tried. Your cooperation and willingness to serve as a juror is appreciated. Your address and telephone number will remain confidential and will not be shared with anyone.
5. First and Last Name:*
6. Juror Number:*
8. Address:*
10. City:*
11. State:*
12. Zip:*
14. Round trip mileage from residence to courthouse if you live outside of Junction City city limits:*
16. Primary contact phone number (10 digits):*
17. Is this phone number a cell phone?*

    1. Yes
    2. No
18. Work phone number:
20. Age:*
21. Email Address
23. Gender*

    1. Male
    2. Female
25. Marital Status:*

    1. Single
    2. Married
    3. Divorced
    4. Widowed
27. Number of Dependents*
29. Age of Dependents
31. Highest grade of education you've completed:*
33. Have you had vocational or professional training?*

    1. Yes
    2. No
35. If yes, what training?
37. Length of residence in Kansas:*
39. Length of residence in Geary County:*
41. Employment Status:*

    1. Employed
    2. Unemployed
    3. Retired
43. Occupation:
45. Employer (if retired, fill out information from last employer):
47. Employer's Address:
49. Spouse Occupation:
51. Spouse Telephone:
53. Are you at least 18 years of age?*

    1. Yes
    2. No
55. Are you a citizen of the United States?*

    1. Yes
    2. No
57. Are you a resident of Geary County?*

    1. Yes
    2. No
59. Are you able to understand the English language?*

    1. Yes
    2. No
61. Are you currently declared incompetent?*

    1. Yes
    2. No
63. Have you been convicted of a felony within the past 10 years?*

    1. Yes
    2. No
65. Have you served as a juror in this county within the past year?*

    1. Yes
    2. No
67. Are you a breastfeeding mother?*

    1. Yes
    2. No
69. If yes, state the approximate date you anticipate breastfeeding will be discontinued:
    If yes, state the approximate date you anticipate breastfeeding will be discontinued:
71. Is there a reason you cannot serve as a juror on the date for which you have been summoned?*

    1. Yes
    2. No
73. If yes, please state your reason:
75. Have you ever served as a juror?*

    1. Yes
    2. No
77. If yes:

    1. Civil
    2. Criminal
79. Have you or any members of your immediate family been a party to any civil or criminal lawsuit?*

    1. Yes
    2. No
81. If yes, what type of lawsuit? Who in your family was involved? When and where did it occur?
85. I CERTIFY THAT ALL ANSWERS ARE TRUE AND CORRECT.
87. Print Full Name:*
88. Date:*
    Date:
Leave This Blank:


90. 1. Receive an email copy of this form.
91. Email address

    This field is not part of the form submission.

92. Submit Submit and Print

* indicates a required field