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Juror Absence Request Form

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Name*
Phone
Address*
Occupation
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).
Absence Days*
Reason(s)*
How would you like to be notified?*
1. Email
2. Post Office Mail
3. Both Email and Post Office Mail
Email Address*
Electronic Signature (Please type your First and Last Name)*
Checking this box constitutes my legal signature.*
1. I understand

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Juror Absence Request Form