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2. First Name
3. Last Name
5. Address
7. City
8. State
9. Zip Code
11. Phone Number
12. Email Address
14. Juror Number
16. Juror Disqualifications

    List all that apply: 

    1. I am currently incarcerated. 
    2. I have served on a jury in Oregon within the last 24 months. 
    3.  I am not a citizen of the United States.  
    4. I have been sentenced to a felony or misdemeanor crime. 
18. Exemption/Hardship Reasons

    I wished to be excused because (list all that apply):

    1. I am over 70 years of age. 
    2. I am the sole care giver of child or dependent (explain above) 
    3. I am currently breastfeeding. 
    4. Jury service will be a hardship due to language, military service, or other reasons (explain above) 
    5. Medical condition (physicians note required) 
    6. Other (explain above).  
20. Requesting a Deferral of Service

    If you are unable to serve for a specific date(s) during your term of service you may request to be excused during those dates. Please list any such circumstances in the space above. 

22. Marital Status
24. Do you have Minor Children?

    If yes list number of children and ages. 

26. Have you Previously served as a juror?

    If yes, what type of trial (civil or criminal) did you serve as juror on? 

28. Have you or an immediate family member been a victim of a crime?
30. Are you related to or a close friend of a police officer?
32. Highest level of Education

    Please explain any specialized training. 

34. Current Occupation and employer

    If retired please provide last occupation. 

36. Spouse/ Partner Occupation

    if retired please provide last occupation. 

38. Have you or anyone in your immediate family been convicted of a crime?

    If yes please list crime, year of conviction, and jail or prison sentence. 

40. Do you have any disabilities impairing you capacity as a juror?

    examples: impaired eyesight or hearing. If yes, please state the nature and extent of your impairment. 

42. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) the information provided is true and accurate to the best of your knowledge, 2)your questionnaire will not be signed in the sense of a traditional paper document, 3) 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. 

    1. I agree.
44. Electronic Signature
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46. 1. Receive an email copy of this form.
47. Email address

    This field is not part of the form submission.

48. Submit

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