(a) In accordance with an agreement, if any, under § 8-213 of this title, a juror qualification form in substantially the following form shall be provided to each prospective juror:

Name:

Resident address:

Telephone: (home) __________ (work) __________ (cellular) __________

Age: __________ Date of Birth:__________

If you are over 70 years of age, do you wish to be exempted from jury services? __________Yes __________No

U.S. Citizen? __________Yes __________No

Able to comprehend, read, speak, and write English? __________Yes __________No

Highest level of education completed: ___ high school ___ college ___ graduate school ___ other

Occupation of prospective juror: __________

Name of employer: __________

Occupation of spouse, if any: __________

Disability preventing satisfactory jury service? __________Yes __________No

Do you want an accommodation under the federal Americans with Disabilities Act? __________Yes __________No

Pending charge for a crime punishable by imprisonment exceeding 1 year? __________Yes __________No

Conviction of crime punishable by imprisonment exceeding 1 year and received a sentence of imprisonment for more than 1 year and not legally pardoned? __________Yes __________No

Date of Conviction __________

__________Elected official of the federal Legislative Branch, as defined in 2 U.S.C. § 30a.

__________Active duty member of armed forces exempted in accordance with 10 U.S.C. § 982.

__________Member of Maryland's organized militia exempted in accordance with Public Safety Article § 13-218.

Prior jury service within 3 preceding years: __________

Form completed by me __________ Another (name) __________ and, if another, why?

Under the penalties of perjury, the responses are true to the best of my knowledge

Signed:__________

Individual completing form for prospective juror:

This form must be completed, signed, and returned to the jury commissioner within 10 days after receipt. Documentation for excusal due to disability, exemption based on armed forces or militia service, pardons, and/or prior jury service must be attached.

(b) A juror qualification form for a county may include other questions as the county's jury plan requires.