2. First Name:*
4. Last Name:*
6. Date to appear:*
8. Jury Number:*
10. Exemption or Disqualification*

    1. Exemption
    2. Disqualification
12. 
    Please Check the following Exemption you are Claiming:*

    1. You are over 70 years old
    2. You have legal custody of a child or children younger than 12 years of age and service on the jury would require leaving the children without adequate supervision
    3. you are a student at a public or private high school
    4. you are enrolled and attend college
    5. You are an officer or employee of the senate, the house of representatives or any department, commission, board, office or agency in the legislative brand of state government
    6. you are the primary caretaker of a person who is an invalid unable to care for himself or herself. (this exemption does not apply to health care workers.)
    7. You are a member of the United State military forces serving on active duty and deployed to a location away from the person's home station and out the person's county of residence.

14. 
    To serve as a juror you must meet qualifications: Please check the following Disqualification you are claiming:*

    1. Be at least 18 years old
    2. be a citizen of this state and a resident of the county in which you are to serve as a juror
    3. be qualified under the Constitution and laws to vote in the county in which you are to serve as a juror ( Note: you DO NOT have to be registered to vote to be qualified to serve as a juror)
    4. be of sound mind and good moral character
    5. be able to read and write
    6. not have served as a juror for six days during the preceding three months in the county court or during the preceding six months in the district court
    7. not have been convicted of misdemeanor theft or any felony
    8. not under indictment or other legal accusation of a misdemeanor theft, felony theft or any other felony charge

16. 
    I DO HEREBY CERTIFY UNDER PENALTY OF PERJURY THAT I AM:*

    1. EXEMPT because of the reason checked above
    2. DISQUALIFIED because of the reason checked above
18. Date:*
20. Email address?*
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22. Submit

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