Cassia County, Idaho

*First Name

*Last Name

*Date of Birth

*Male/Female

*Age

*Email Address

Home Phone

Work Phone

*Cell Phone

I would like to receive Jury notification via:

E-mail

E-mail

Text

Text

Wireless Service Provider

Years in Idaho

Years in Cassia County

Prior Place of Residence

*Marital Status

Married

Single

Divorced

Separated

Widowed

Spouse's Name

Number of Children

Ages of Children

Your Occupation and Employer (If retired, former occupation)

Spouse's Occupation and Employer (If retired, former occupation)

*Have you or any member of your immediate family been a party to a lawsuit?

Yes

If Yes, What Type? When? and Where?

*Have you ever been a defendant in a criminal action other than a traffic violation?

Yes

If so, when and where?

*Has a lawsuit for bodily injury ever been filed against you?

Yes

*Have you ever filed a lawsuit for bodily injury?

Yes

*Do you drive an automobile?

Yes

*Are you related to or a close friend of any law enforcement officer?

Yes

*Have you served as a juror prior to this term?

Yes

If so, When and Where?

*One way mileage to the Judicial Center:

*Highest year of education completed:

*Current Student?

Yes

DISQUALIFICATIONS: Please check all that apply to you.

I am NOT a citizen of the United States of America.

I am NOT a citizen of the United States of America.

I am a citizen of:

I am NOT able to read, write, or understand the English language.

I am NOT able to read, write, or understand the English language.

I am NOT a resident of Cassia County.

I am NOT a resident of Cassia County.

I am a resident of, or in the military stationed at:

I have been convicted of a felony and I am presently on probation/parole.

I have been convicted of a felony and I am presently on probation/parole.

If so, What County and State?

OR have NOT been restored to the rights of citizenship pursuant to Idaho Code §18-310.

OR have NOT been restored to the rights of citizenship pursuant to Idaho Code §18-310.

Within the past 24 months, I have served on a jury or answered roll call.

Within the past 24 months, I have served on a jury or answered roll call.

If so, When and Where?

I am 70 years of age or older and wish to be excused.

I am 70 years of age or older and wish to be excused.

If you wish to be excused because you are 70 years or older it is not necessary to complete the rest of this form. Add you name and Date of Birth here:

POSTPONEMENTS: A written explanation may be attached here for any items checked below.

REQUEST FOR POSTPONEMENT: If you are requesting a postponement, please contact the Jury Commission by phone or email us at: jury@cassiacounty.org. ONLY ONE POSTPONEMENT WILL BE GRANTED.

REQUEST FOR POSTPONEMENT: If you are requesting a postponement, please contact the Jury Commission by phone or email us at: jury@cassiacounty.org. ONLY ONE POSTPONEMENT WILL BE GRANTED.

MEDICAL: Excuse from your medical doctor can be faxed to (208) 878-1003 or scanned and e-mailed to jury@cassiacounty.org

REQUEST FOR EXCUSE: The State of Idaho and Cassia County recognize no exemptions from jury service except those with severe medical problems which are SUPPORTED BY A MEDICAL DOCTOR'S CERTIFICATE.

It will be sent or E-mailed.

It will be sent or E-mailed.

Dr.'s Office will be sending Fax.

Dr.'s Office will be sending Fax.

If you have a physical condition that affectsyour ability to communicate, or that may require other accommodations, please call the Jury Commission at (208) 878-8610.

Request for Exemptions: Idaho Code §2-211 states: "No exemptions for any qualified prospective juror may be granted."

*The responses to the questions on this qualification form are true to the best of my knowledge. Idaho Code §2-208 (6) Any person who willfully misrepresents a material fact on a qualification questionnaire form for the purpose of avoiding or securing service as a juror is guilty of a misdemeanor.

The responses to the questions on this qualification form are true to the best of my knowledge. Idaho Code §2-208 (6) Any person who willfully misrepresents a material fact on a qualification questionnaire form for the purpose of avoiding or securing service as a juror is guilty of a misdemeanor.

Jury Test