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Full Name: (Please Print) as) (First) (Middle Tnitialy I declare under penalty of perjury that the answers set forth in this Juror Questionnaire are true and correct to the best of my knowledge and belief. Ihave not discussed my answers with others or received assistance in completing the questionnaire, Signed this 13th day of May, 2019. (Signature) Name: BACKGROUND INFORMATION ee jee What is your age? Place of birth? How long have you been a resident of the state of Hawaii? ‘What is your current status? O Single O Married C1 Living together Divorced Separated 1 Widowed What is your current occupation? Check all that apply: Gj Work full-time Cl Work part-time CO Homemaker Student OG Disabled O Retired Cl Unemployed Gi Other (please specify) If employed, please indicate your employer, the type of work you do and how Iong you have been employed in that capacity. If you are retired or unemployed, describe the work you used to do and how long you have been retired or unemployed. What other full-time employment have you had during your working life? ‘Name: 7. How far did you go in school, and what was your major field of study if you went to college or graduate school? (If you are currently a student, what is your field of study?) 8. How far did your spouse/partner go in school, and what was his or her field of study? 9. For each member of your household or any adult children living outside the household, please provide the following information: Relationship Occupation Example: Husband Teacher Mf ut it