Juror Qualification Form

If you complete and successfully submit this online summons form, you do not need to return the summons card that was mailed to you.
Full Name:    
Date Of Birth: (mm/dd/yyyy)     
Service Date: Calendar    
Summons Number:    
Home Phone:  
Work Phone:  
Email Address: (Optional. For excusals, email is required.)   
Occupation:
(if retired, list previous
occupation)		  
Gender:      
Current Address:    
1. Are you a resident of Erie County?

  
2. Are you a citizen of the United States?

  
3. Do you read, write and speak the English language?

  
4. Are you a full time student?

  
    If yes, where?

 
5. Are you on active duty in the Armed Forces?

  
6. Have you ever been convicted of a felony?  
    If Yes, state when and where:


  
7.
Have you served as a juror within the past three years?
If so, how many days did you serve?

 
 
If yes, do you wish to waive your three year jury service exemption and serve now?

  
8. Is there any reason why you cannot participate in jury service?

  
    If you wish to be excused, state your reason below:
(If applicable, fax doctor's certificate to (814) 451-7699)
  
9. Please indicate your race (optional):





If other, specify:

10. Can you demonstrate that jury duty will cause undue hardship?
If so, please explain:

  
 

Subject to the penalty for perjury, I declare, swear or affirm that the foregoing statements on all sections of this form are true to the best of my knowledge and belief, and I will appear on the date summoned unless otherwise excused.