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County of Santa Clara (The Superior Court of California, County of Santa Clara)

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Supervisorial District:
(for staff use only)
Superior Court of California
County of Santa Clara
2021 Civil Grand Jury Application and Nomination Form
□ Mr. □ Mrs. □ Ms. □ Dr. □ Mx. □ No title
1. Name:
Last First Middle
2. Residence Address:
Street City Zip
3. Home Phone: ( ) Cell Phone: ( )
E-mail:
Gender: □ Man (or male) □ Woman (or female) □ Non-binary □ Decline to answer
Date of Birth: / / Place of Birth:
Age Range: □ 18-25 □ 26-34 □ 35-44 □ 45-54 □ 55-64 □ 65-74 □ 75 and over
Driver License or State ID Number:
Indicate your race/ethnicity by checking all that apply:
□ American Indian or Alaska Native □ Hispanic/Latino
□ Asian □ Native Hawaiian or other Pacific Islander
□ Black or African American □ White
□ Other Race or ethnicity (please state):____________________ □ Decline to answer
Sexual Orientation: □ Gay □ Lesbian □ Bisexual/pansexual □ Straight/heterosexual
□ Queer □ Another sexual orientation □ Decline to answer
4. Student: □ Yes/No □
5. Employment Status: Presently Employed □
Not Employed □
Retired □
6. Please provide detailed (present and/or past) employment (10 years or two most recent
jobs) and educational background information on a separate sheet of paper.
Resume is attached: □ Yes/No □
, State
Superior Court of California
County of Santa Clara
2021 Civil Grand Jury Application Last Name:
2
7. If you are employed, does your employer understand the nature of the duties of a Grand
Juror and will they release you to full-time Grand Jury service for the entire period that
the jury shall be in session? Yes □ No □
If you are
currently
employed, a
written release verification
from your employer
MUST BE ATTACHED TO THIS APPLICATION.
EMPLOYERS ARE NOT REQUIRED TO PAY WAGES TO CITIZENS SERVING ON
THE CIVIL GRAND JURY.
8. Name of Spouse/Significant Other:
Spouse/Significant Other’s Occupation/Employer:
Pursuant to California Rules of Court, Rule 1.100 and the Americans with Disabilities Act (ADA), the Superior
Court of California, County of Santa Clara, does not discriminate against persons with disabilities.
9. 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)
10. Are you a citizen of the United States? Yes □ No □
11. Do you read and understand English? Yes □ No □
12. 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 December 17, 2020?
Yes □ No □
13. Are you a registered voter? Yes □ No □
14. The Political Reform Act (Gov. Codes § 81000, 84100 et seq.) requires most state and local
government officials and employees who make or participate in the decision-making
process to publicly disclose their personal assets and income. If you are selected as a
member of the Civil Grand Jury, you will be required to complete a Statement of Economic
Interests (Form 700).
Are you willing to complete the Form 700? Yes □ No □
Superior Court of California
County of Santa Clara
2021 Civil Grand Jury Application Last Name:
3
15. Are you related to or closely associated with any elected official or public employee?
Yes □ No □
If yes, please give their name(s) and explain relationship(s):
16. Are you currently serving as an elected public official? Yes □ No □
Title: Date term ends:
17. Have you ever been convicted of any of the following?
Malfeasance in Office Yes □ No □
Felony Yes □ No □
Misdemeanor Yes □ 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. Please provide additional information on a separate sheet if
necessary.
Offense City/State Date Penalty
18. 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 □
19. Are you contemplating any absence from Santa Clara County in the Calendar Year
2021, which might interfere with your performance as a Grand Juror?
Yes □ No □
If yes:
Departure Date: Return Date:
Superior Court of California
County of Santa Clara
2021 Civil Grand Jury Application Last Name:
4
20. If selected as a finalist, will you be able to attend the mandatory Drawing/Impanelment
Ceremony on Thursday, December 17, 2020, at 4 pm? Yes □ No □
21. Training pursuant to Penal Code § 914 for the 2021 Civil Grand Jury is tentatively
selected for the 2021 Civil Grand Jury attend these meetings.
Will you be able to attend all of the mandatory training sessions? Yes □ No □
22. 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 neither
the Grand Jury, nor anything which I or any other Grand Juror may say, or 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.”
Do you have any objections to taking such an oath or affirmation?
Yes □ No □
23. Will you define and evaluate issues without expressing personal bias?
Yes □ No □
24. Are you aware that the Civil Grand Jury is required to publish a final report of issues
they have investigated? Yes □ No □
25. Are you willing to investigate county government issues and prepare reports on these
issues? Yes □ No □
26. Please outline your knowledge and understanding of the role and function of the Civil
Grand Jury and of county government. (Attach additional sheets if necessary)
27. Why do you want to serve on the Civil Grand Jury and what contributions would you
hope to make as a member? (Attach additional sheets if necessary)
scheduled on January 7 and 8, 2021. It is mandatory that each of the persons
Superior Court of California
County of Santa Clara
2021 Civil Grand Jury Application Last Name:
5
28. 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?) □ Community Organization
□ TV/Radio (which?) □ Public Gathering
□ Social Media (which?) □ Government Agency (which?)
□ Referred by □ Other
29. Have you ever served on the Santa Clara County Civil Grand Jury?
If yes, list the year(s):
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 , California.
City
Signature: Dated:
For Court Use Only
The above candidate is suitable, competent and qualified to serve as a Grand Juror, for the
Calendar Year 2021 under Sections 893 and 896 of the California Penal Code. I have discussed
the requirements for Grand Jury service and have ascertained availability for service.
Date HON. DEBORAH A. RYAN
Presiding Judge of the Superior Court
State of California, County of Santa Clara
Yes No
o o
Superior Court of California
County of Santa Clara
2021 Civil Grand Jury Application Last Name:
6
APPLICANT STATEMENT
I, , understand that my name may be placed in nomination to be
considered for membership on the Civil Grand Jury of Santa Clara County for the Calendar Year 2021.
I understand that the term will be from January 4 to December 31, 2021.
I am aware that such service requires that I be in attendance at least 25 hours per week and frequently more.
In this regard, I understand that as a Grand Juror, I must be flexible and able to serve some evening and weekend
hours as well as working during normal business hours as determined by the 2021 Civil Grand Jury. I declare,
pursuant to Penal Code § 896(a), that I will be available to serve during those required hours.
Each member of the Grand Jury shall be allowed a per diem for each day’s attendance, either at general sessions
or committee assignments of the Grand Jury. Mileage expense (nontaxable) is also compensated each mile
actually and necessarily traveled for purposes of said sessions or committee work.
Now, therefore, I have read and understand the above and I hereby state that I have no commitments which
would prevent me from meeting the requirements for service on the Santa Clara County Civil Grand Jury.
I recognize that my attendance will be expected and may be required by the Foreperson of the Grand Jury.
I fully understand that the Civil Grand Jury staff will conduct a background check. Furthermore, I understand
that I must complete a Form 700.
I therefore request that I be considered as a candidate for the Civil Grand Jury of Santa Clara County for the
Calendar Year 2021.
Signature (Full Name) Date
REMINDER:
Please provide
DETAILED
(PRESENT and
/or
PAST)
employment (10 years or two
most recent jobs) and educational background information.
Please be sure to
sign
and return this completed application to:
Britney J. Huelbig
Deputy Manager, Civil Grand Jury
Santa Clara County Superior Court
191 North First Street
San José, California 95113
Deadline to Apply: September 25, 2020
Web address: www.scscourt.org (Click on Civil Grand Jury)
Submit Application
Superior Court of California
County of Santa Clara
2021 Civil Grand Jury Application Last Name:
7
APPLICANT CHECK LIST
(Please do not submit this form with your application)
Application completed, and signed and dated, page 5
Applicant Statement signed and dated, page 6
Included employment and educational background information
Answered YES/NO questions #10 - 25, pages 2 – 4
IMPORTANT DATES TO REMEMBER – MANDATORY ATTENDANCE
Impanelment Ceremony Virtual Event Thursday, December 17, 2020
Grand Jury Orientation Virtual Event Thursday, January 7, 2021
Grand Jury Legal Training Virtual Event Friday, January 8, 2021
To be determined: California Grand Jurors' Association Training
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Completed 29 June 2021

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