California > Local County > Marin > Juror
Medical Exemption Request JUR001 - California
| Medical Exemption Request Form. This is a California form and can be used in Juror Marin Local County . |
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MARIN COUNTY SUPERIOR COURT OFFICE OF JURY SERVICES P.O. Box 4988 San Rafael, CA 94913-4988 (415) 444-7120 · Fax (415) 444-7121 TO: FROM: Juror or Physician Marin County Superior Court Office of Jury Services Request for Exemption from Jury Duty Due to Medical or Careprovider Reasons RE: JUROR: If you are requesting exemption from jury duty due to medical or careprovider reasons, the attached form must be completed by a physician. Forms that are incomplete or not signed by a physician will result in a denial of your request. Please note that your summons date was changed to allow enough time to return the form. You or your physician must return the completed form by mail and FAX at least five days prior to your summons date. You will receive written notice of the Jury Commissioner's decision by mail. PHYSICIAN: Please complete each question on the form and return it to the Jury Office by mail and FAX at least five days prior to the patient's summons date. MAIL TO: Office of Jury Services P.O. Box 4988 San Rafael, CA 94913-4988 (415) 444-7121 FAX TO: JUR006 EXEMPTION REQUEST COVER LETTER (Mandatory Form) Rev. 11/11 American LegalNet, Inc. www.FormsWorkFlow.com MARIN COUNTY SUPERIOR COURT OFFICE OF JURY SERVICES P.O. Box 4988 San Rafael, CA 94913-4988 (415) 444-7120 · Fax (415) 444-7121 MEDICAL EXEMPTION REQUEST THIS SECTION MUST BE COMPLETED BY PATIENT PATIENT'S NAME __________________________________________ JUROR ID# Date of Birth _________________________ Date of Summons Are you presently working full or part-time? THIS SECTION MUST BE COMPLETED BY A PHYSICIAN PHYSICIAN'S NAME (print or type) PHYSICIAN'S PHONE # ADDRESS 1. What specific condition will preclude the individual from serving on a jury? 2. Why should the condition preclude the individual from serving on a jury? 3. What may the Court do to reasonably accommodate this condition, thereby allowing the individual to serve on a jury? 4. Will the condition preclude the individual from serving on a temporary or permanent basis? If temporary, how long? 5. The date of any operation, future treatment or appointment which could conflict with an individual serving on a jury. DATE:________________ PHYSICIAN'S SIGNATURE __________________________________________________ DATE JUR001 MEDICAL EXEMPTION REQUEST (Mandatory Form) Rev. 11/11 American LegalNet, Inc. www.FormsWorkFlow.com
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