Name *

First Name

Last Name

Phone

(###)

###

####

Date of Jury Service *

Please type the date indicated on your summons.

MM

DD

YYYY

Please check whether any of the following apply to you:

I am 70 years of age or older, and do not want to serve as a juror.

I am not a resident of St. Tammany Parish.

I have been under indictment, incarcerated under an order of imprisonment, or on probation or parole for a felony offense within the past five years.

I have a physical or mental infirmity which renders me incapable of serving.

I have an unlying health condition, including high blood pressure, chronic lung disease, diabetes, obesity, asthma, compromised immune system which makes me a vulnerable individual.

I have COVID-19 health concerns.

It is within 48 hours of my scheduled jury service and I am experiencing:

fever

cough

other symptoms which may indicate I have COVID-19