Question 1
Print your occupation at the present time in the space provided. If you are unemployed or retired, indicate this.

Question 2
Print your business and residential telephone number as applicable including area code. One number for each is satisfactory.

Question 3
If you have good knowledge and command of the French language, mark the yes box with an X - if not mark the no box with an X.

Question 4
If you have good knowledge and command of the English language mark the yes box with an X - if not mark the no box with an X.

Question 5
If at present you are a Canadian citizen mark the yes box with an X - if not mark the no box with an X.

Question 6
Anyone over the age of 18 can serve as a juror. There is no maximum age limit. If at present you are 18 years of age or more, mark the yes box with an X - if not mark the no box with an X.

Question 7
If you have been convicted of an indictable offence for which you have not been granted a pardon, then mark the yes box with an X. To obtain information regarding a pardon, contact your local police station. If you are unsure as to whether or not your offence was indictable please check the explanation note below this QUESTION or contact your local police station or the court office where the offence took place. If your offence was not indictable, or if you have not been convicted of an indictable offence, then mark the no box with an X.

Question 8
If you have attended the COURTHOUSE in response to a summons for jury service in the last three years regardless of whether you were selected to serve on the jury or not, mark the yes box with an X - If not mark the no box with an X.

Question 9
Please refer to the occupations below this QUESTION for clarification of occupations that are exempt from jury duty. If your occupation falls under any of the categories listed, mark the yes box with an X and also ensure you indicate your occupation in Question 1. If your occupation does not fall under any of these categories, then mark the no box with an X.

Question 10
If you have any physical or mental disability or medical condition which you feel would not allow you to serve as a juror, mark the yes box with an X and fill out the "Authorization for Doctor to Provide Medical Information" located beneath QUESTION # 10. There is no requirement to obtain or include a doctor's letter. If you do not have a physical or mental disability or medical condition which would prevent you from serving as a juror, mark the no box with an X.

If you have received a QUESTIONNAIRE for an individual who has a physical or mental disability or medical condition which would not allow them to serve as a juror, mark the yes box with an X in Question 10 and fill out the "Authorization for Doctor to Provide Medical Information" located beneath QUESTION #10. There is no requirement to obtain or include a doctor's letter.

Please make sure that you sign the questionnaire and date the bottom of the form. Once you have completed it, return the questionnaire by mail in the postage paid envelope provided.

For comments or questions related to jury duty, please email juryduty@jus.gov.on.ca.