Douglas County Forms

2. I am eighty (80) years of age.

   1. I hereby attest that I am eighty (80) years of age or older and am unable to serve due to health reasons.
4. Breastfeeding and/or expressing milk for infant under 24 months.

   1. I hereby attest that I am unable to serve as a juror due to breastfeeding and/or expressing breastmilk for an infant under 24 months.
6. Electronic Signature Agreement*

   By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) 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, and 3) you may still be required to provide a traditional signature at a later date.

   1. I agree.
8. I hereby state under penalty of perjury under the laws of the state of Washington that the foregoing is true and correct.
10. Electronic Signature
11. Juror #*

    Juror number can be found on summons.

15. Please provide the requested information below.

17. Name
18. Email Address
20. Address
22. City
23. State
24. Zip Code
26. Phone Number
Leave This Blank:


28. 1. Receive an email copy of this form.
29. Email address

    This field is not part of the form submission.

30. Submit

* indicates a required field