Qualified Juror Questionnaire

Your Full Name: *
Your Email Address: *
Your Cell Phone Number: *

Jury Term Date: *

List your employer and your position: *

What area of Madison County do you live in? *

Who is your automobile insurance carrier? *

Are you an officer, director, stockholder, employee of an insurance company? If yes, what company?

Do you have any reason that would prevent you from sitting on a case that could take longer than one week in trial? *

Emergency Contact: *
Emergency Contact Number: *

Today's Date *

I acknowledge that checking the box, entering my name below, and clicking the Submit button serves as my electronic signature.

Enter your name: *

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