First Name Middle Name Last Name What is your age? Education - Highest grade completed Are you a citizen of the United States? Are you a citizen of the United States? Yes No Are you a resident of Lewis County? Are you a resident of Lewis County? Yes No Are you able to communicate in English? Are you able to communicate in English? Yes No Have you ever been convicted of a felony? Have you ever been convicted of a felony? Yes No If yes, have your civil rights been restored? If yes, have your civil rights been restored? Yes No Are you related to or personal friends of any law enforcement officer? Are you related to or personal friends of any law enforcement officer? Yes No Have you ever been convicted of a crime other than a minor traffic violation? Have you ever been convicted of a crime other than a minor traffic violation? Yes No Are you currently employed? Are you currently employed? Yes No If yes, state your occupation Employers name and address If retired or unemployed, what was your prior occupation if any? Is your spouse employed? Is your spouse employed? Yes No 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? Have you ever served on a jury? Yes No 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 This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply. View PDF of Page
