2. Due within 7 calendar days prior to trial.

   The purpose of this questionnaire is to identify jurors who have a reason recognized by law as making them presumptively unable to serve on a jury at this time. Please answer the questions completely and accurately. 

4. Name*
6. Age*
7. Jury Panel #*
8. Juror Number*
10. Are you a citizen of the United States, as required by law to participate in jury service? *

    1. Yes
    2. No
12. Are you a resident of Pierce County, as required by law to participate in jury service? *

    1. Yes
    2. No

    Non-Pierce County residents require proof of change of address.

    
    

14. Are you at least 18 years old, as required by law to participate in jury service? *

    1. Yes
    2. No
16. Are you able to read, speak, and understand the English language, as required by law to participate in jury service?*

    1. Yes
    2. No
18. Are you a convicted felon and your civil rights have not been restored?

    1. Yes
    2. No
20. Are you unable to serve on a jury because of a physical or mental disability? *

    1. Yes
    2. No
21. If "yes," please explain:
23. Are you solely responsible for the daily care of an individual with a permanent disability who lives with you? *

    1. Yes
    2. No
24. If "yes," please explain:
26. Have you served on a jury within the last 12 months, or are you scheduled for jury service within the next 12 months?*

    1. Yes
    2. No
27. If "yes," please explain:
31. Is there any other reason you might not be able to serve as a juror? *

    1. Yes
    2. No

    Medical reasons require a letter from doctor. Vacation or travel require itinerary or flight reservation. 

32. If "yes," please explain:
36. Please check the appropriate box indicating if any of the following apply to you:

    1. I am currently ill and have tested positive for COVID19.
    2. I am currently ill and I am concerned that I may test positive for COVID19.
    3. I am not currently ill but in the last 14 days was around someone who recently tested positive for COVID19.
    4. I am caring for a family member or loved one who has tested positive for COVID19.
40. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    
    

    1. I agree.
42. Electronic Signature*

    
    

    By signing above, I swear or affirm under penalty of law that I have truthfully answered these questions

43. Date*
    Date
45. Phone Number*
Leave This Blank:


47. 1. Receive an email copy of this form.
48. Email address

    This field is not part of the form submission.

49. Submit

* indicates a required field