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2. Name*
3. Date of Birth*
   Date of Birth
5. Juror Number*
6. Panel Name*
8. Address (If you are no longer a Westminster resident, please enter your updated address)
10. City
11. State
12. Zip Code
14. Phone Number*
15. Email Address*
17. Request for Disqualification or to be Excused

    1. I am not a citizen of the United States.
    2. I am under the age of 18.
    3. I do not read, speak or understand English.
    4. I do not live in the City of Westminster (Please provide new address in the Address field)
    5. I am solely responsible for the daily care of a permanently disabled (physical or mental) person living in my home.
    6. I am unable to serve as a juror due to a medical reason (physical or mental). Please note that reasonable accommodations must be made as a result of a physical disability to permit you to serve as a juror.
    7. I have served as a juror in a municipal, tribal, military, state or federal jury in the past year.
    8. I am scheduled to serve or appear as a juror in a municipal, tribal, military, state or federal jury in the next twelve months.
19. Please state the reason for your request
21. Please attach documentation to validate your request if available
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23. 1. Receive an email copy of this form.
24. Email address

    This field is not part of the form submission.

25. Submit

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