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2. Name*
3. Phone
5. Address*
7. Occupation
9. Dear Judge of the Circuit Court for the City of Salem,*

   1. I am requesting that you excuse me from serving as a juror for the following dates and reasons(s).
   2. I am requesting that you excuse me from serving as a juror for the entire term for the following reason(s).
11. Absence Days*
13. Reason(s)*
15. How would you like to be notified?*

    1. Email
    2. Post Office Mail
    3. Both Email and Post Office Mail
17. Email Address*
19. Electronic Signature (Please type your First and Last Name)*
21. Checking this box constitutes my legal signature.*

    1. I understand
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23. 1. Receive an email copy of this form.
24. Email address

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