"*" indicates required fields First Name* Last Name* Email* Address* Street Address Address Line 2 City ZIP Code State*AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasU.S. Minor Outlying IslandsUtahVermontVirgin Islands (U.S.)VirginiaWashingtonWest VirginiaWisconsinWyomingCounty*– Fill Out Other Fields –If the State and County fields doesn’t load, double-check your internet connection and refresh the page.Cell Phone*LandlineDate of Birth* YYYY dash MM dash DD Are you a US citizen?* Yes No Do you have a current valid driver's license or State ID?* Yes No Are you a registered voter?* Yes No Ethnic Background* White/Caucasian Black/African American Hispanic/Latino/Latina Asian-American Native American/Other Gender* Male Female Transsexual Non-Binary Other Marital Status* Never Married Married Separated Divorced Widowed Living with Partner/Significant Other Employment Status* Employed Self Employed Homemaker Retired Student Disabled Unemployed/Other How would you characterize your occupation?* Blue Collar Clerical Sales Service Professional White Collar Student Homemaker Other Annual Household Income* Less than $25,000 $25,000 – $50,000 $50,000 – $75,000 $75,000 – $100,000 $100,000 – $150,000 $150,000 + Highest Level of Education* Less than High School High School Graduate or GED Some College/No Associate’s Degree Some College/Vocation/Technical School Completion Junior College/Associate’s Degree College Degree/Bachelor’s Degree Some Graduate Study Graduate/Professional Degree Political Stance* Very Liberal Somewhat Liberal Middle of the Road Somewhat Conservative Very Conservative Consent* By checking this box, I am attaching my electronic signature to and agreeing to the Site Usage Agreement for the OnlineVerdict.com Website and services, and to the OnlineVerdict.com Privacy Policy. I understand that if I do not agree to these Terms and Conditions and the Privacy Policy, I should not check this box, discontinue submission of my personal information, and refrain from using the OnlineVerdict.com Website and service.*Confidentiality* I agree to keep confidential the facts and names of all of the parties in cases on which I serve as an OnlineVerdict.com juror.*EmailThis field is for validation purposes and should be left unchanged. Δ
