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Civil Grand Jury Application And Nomination Form AD-1017 - California
| Civil Grand Jury Application And Nomination Form Form. This is a California form and can be used in Jury Santa Clara Local County . |
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Supervisorial District: (for staff use only) Superior Court of California County of Santa Clara 2013-2014 CIVIL GRAND JURY APPLICATION AND NOMINATION FORM PLEASE PRINT IN BLACK INK OR TYPE Mr. 1. 2. 3. Name: Last Mrs. Ms. Sex: First Middle M F Residence Address: Street City Zip Home Phone: ( Fax Number: ( ) ) Cell Phone: ( E-mail: ) Date of Birth: / / Place of Birth: Drivers License or State ID Number: Indicate your ethnic derivation by checking one of the following: American Indian or Alaska Native Asian Black or African American Other Race or ethnicity; please state: Decline to answer Hispanic/Latino Native Hawaiian or other Pacific Islander White 4. Employment Status: Presently Employed Not Employed Retired Employer: 5. 6. If Presently Employed, Occupation: Business Address: Street City Zip Business Phone: ( ) Please provide DETAILED (PRESENT and/or PAST) employment and educational background information on separate sheet of paper. AD-1017 Rev. 02/13 American LegalNet, Inc. www.FormsWorkFlow.com Superior Court of California County of Santa Clara Civil Grand Jury Application, 2013-2014 Last Name: 7. Name of Spouse: Spouse's Occupation/Employer: Pursuant to California Rules of Court, Rule 989.3 and the Americans with Disabilities Act (ADA), the Superior Court of California, County of Santa Clara, does not discriminate against persons with disabilities. 8. Do you require any accommodations for a mental or physical condition (including impaired hearing, eyesight or mobility) to enable you to participate in the application process or as a Grand Juror? (Please explain) 9. Are you contemplating any absence from Santa Clara County in Fiscal Year 2013-2014, which might interfere with your performance as a Grand Juror? Yes No If yes: Departure Date: Return Date: If selected as one of the finalists, will you be able to attend the Drawing/Impanelment Yes No Ceremony on Thursday, June 27, 2013 at 4:00 PM? (Attendance is Mandatory ) Please Note: A training program pursuant to Penal Code § 914, for the 2013-2014 Civil Grand Jury is tentatively scheduled for the second week of July 2013. It is mandatory that each of the 19 persons selected for the 2013-2014 Civil Grand Jury and the first three alternates attend this training session. Will you be able to attend the 2-day training session? 10. Are you currently serving as an elected public official? Title: 11. Date term ends: Yes Yes No No Are you related to or closely associated with any elected official or public employee? Yes No If yes, please give name and explain relationship: AD-1017 Rev. 02/13 -2- American LegalNet, Inc. www.FormsWorkFlow.com Superior Court of California County of Santa Clara Civil Grand Jury Application, 2013-2014 Last Name: 12. Have you ever been convicted of any of the following? Malfeasance in Office Felony Misdemeanor Yes Yes Yes No No No If you have answered "yes," to any of the above please give details below: Please note that a misdemeanor conviction is not an automatic bar to acceptance of application. Each case is considered individually and confidentially. Offense City/State Date Penalty 13. As a member of any profession or organization or as a holder of any office, have you ever been suspended, disbarred or otherwise disqualified? Yes No If selected as a grand juror, you will be required to swear or to affirm the following obligation: "I do solemnly swear or affirm that I will support the Constitution of the United States and the State of California, and all laws made pursuant to and in conformity therewith, will diligently inquire into, and true presentment make, of all public offenses against the people of this state, committed or triable within this county, of which the Grand Jury shall have or can obtain legal evidence. Further, I will not disclose any evidence brought before the Grand Jury, nor anything which I or any other grand juror may say, nor the manner in which I or any other grand juror may have voted on any matter before the Grand Jury. I will keep the charge that will be given to me by the court." Have you any objections to taking such an oath or affirmation? Yes No 14. AD-1017 Rev. 02/13 -3- American LegalNet, Inc. www.FormsWorkFlow.com Superior Court of California County of Santa Clara Civil Grand Jury Application, 2013-2014 Last Name: 15. 16. 17. Are you a citizen of the United States? Do you read and understand English? Yes Yes No No Are you 18 years or older and will you have been a resident of the State of California and of the County of Santa Clara for at least one year as of June 27, 2013? Yes No 18. 19. Are you a registered voter? Yes No Are you able and willing to define and evaluate issues without expressing personal bias? Yes No Are you aware that the Grand Jury is required to publish a final report of issues they have investigated? Yes No Are you willing to investigate county government issues and prepare reports on these issues? Yes No If you are employed, does your employer understand the nature of the duties of a grand juror and will he/she release you to full-time grand jury service for the entire period that Yes No the jury shall be in session? 20. 21. 22. If you are employed, a written release verification from employer MUST BE ATTACHED TO THIS APPLICATION. EMPLOYERS ARE NOT REQUIRED TO PAY WAGES TO CITIZENS SERVING ON THE CIVIL GRAND JURY AD-1017 Rev. 02/13 -4- American LegalNet, Inc. www.FormsWorkFlow.com Superior Court of California County of Santa Clara Civil Grand Jury Application, 2013-2014 Last Name: 23. Why do you want to serve on the Grand Jury and what contributions would you hope to make as a member? (Attach additional sheets if necessary) 24. Please outline your knowledge and understanding of the role and function of the Grand Jury and the role and function of county government. (Attach additional sheets if necessary) 25. Please assist the Court in the evaluation of the Grand Jury recruitment program by indicating from which source you learned about service on the Santa Clara County Civil Grand Jury. Newspaper (which?) TV/Radio (which?) Referred by Community Organization Public Gathering Other I am in possession of all my natural faculties, of ordinary intelligence and of sound judgment and fair character. I certify under penalty of perjury, that all of the statements I have made are true, complete and accurate. Executed at City , California. Dated: Signature: For Court Use Only The above candidate is suitable, competent, and qualified to serve as a grand
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