Jury Summons

First Name: *

Middle Name:

Last Name: *

What is your age?: *

Education - Highest grade completed: *

Are you a citizen of the United States?: *

Yes

Are you a resident of Lewis County?: *

Yes

Are you able to communicate in English?: *

Yes

Have you ever been convicted of a felony?: *

Yes

If yes, have your civil rights been restored?:

Yes

Have you ever been convicted of a crime other than a minor traffic violation?: *

Yes

Are you currently employed?: *

Yes

If yes, state your occupation:

Employers name and address:

If retired or unemployed, what was your prior occupation if any?:

Is your spouse employed?: *

Yes

If yes, state his or her occupation:

Spouse's employer's name and address:

If retired or unemployed, what was his/her prior occupation if any?:

Have you ever served on a jury?: *

Yes

If yes, what years?:

If yes, which court?:

Request for excuse or postponement must be made in writing or by submitting this online form. If you make a request for postponement or exemption, you will receive notice indicating your request has or has not been granted.

Job related or medical exemption must be requested in writing and may not be requested using this online form. Job related exemption requires letter from an employer. Medical exemption requires a letter from your doctor. (Attach letters from employer or doctor to your summons when returning by mail.)

(1) I ask to be excused because:

(2) I ask that my service be postponed because (vacations, prior engagements, etc.) Please list unavailable dates.:

Signature

I declare under penalty of perjury under the laws of the State of Washington that the above is true and that I acknowledge receipt of this summons.

Your name: *

By entering your name in this field, you are indicating your intent to sign this document.

Date: *

Home Phone: *

Work Phone:

Mailing Address: *

Email Address:

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Chehalis Municipal Court
350 N. Market Blvd., Rm 105
Chehalis, WA 98532
Office: (360) 345-1025
Fax: (360) 345-1050

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