Pre-Qualifying Questionnaire LIVINGSTON COUNTY JURY COMMISSION Phone: 815-842-9357 Fax: 815-842-0919 110 North Main Street Second Level Suite 213 Pontiac, IL 61764 Office Hours: Tuesdays 8:30 AM to 11:30 AM, and Wednesdays 10:00 AM to 1:00 PM. You are legally responsible for completing this Pre-Qualifying Questionnaire, and submitting it within 15 days of receipt. This is NOT a Jury Summons. 1. First Name (Required) Last Name (Required) Juror Identification Number Today's Date (mm/dd/yyyy) Street Address (Required) City (Required) Home Telephone (Required) Work Telephone Cell Telephone eMail Address 2. Are you a resident of Livingston County, Illinois? (Required) YesNo 3. Are you a U.S. Citizen? (Required) YesNo 4. Date of Birth (mm/dd/yyyy) Age Gender MaleFemale 5. Occupation Employer 6. Are you married? YesNo If yes, first name of spouse 7. Is your eyesight good? YesNo 8. Is your hearing good? YesNo 9. Do you read, write and understand English? YesNo 10. If you answered "No" to 7,8, and/or 9, please explain: 11. Do you have any physical or mental impairment(s) which would interfere with your jury service? YesNo If you answered yes to 11, please explain: 12. Have you ever served as Juror? YesNo If you answered "Yes", please list the dates and which county: 13. Do you care for a disabled/dependent individual which would interfere with your jury service? YesNo If you Answered "Yes", please explain: 14. Is there any other reason you cannnot serve as a juror? YesNo If you Answered "Yes", please explain: I swear or affirm that the above information is true to the best of my knowledge as it pertains to my qualifications for jury service. Complete this Captcha: