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2. Name:*
3. DOB:
4. Last 4 of SSN XXX-XX
6. # of YRS in Blaine County
7. Prior Place of Residence
8. One way mileage from your residence to the courthouse
10. Gender
    -- Select One --FemaleMaleNon-Binary
11. Marital Status:
    -- Select One --MarriedSingleDivorcedSeparatedWidow (er)
12. Highest year of education completed
14. Number of Children
15. Ages
17. Occupation (Former if Retired)
18. Retired

    1. Retired
19. Employer
21. Spouses Name:
23. Occupation (Former if Retired)
24. Retired

    1. Retired
25. Employer
27. Have you or any member of your immediate family been party to a lawsuit?

    1. YES

    1. NO
29. If yes explain nature:
31. Have you ever been a defendant in a criminal action OTHER than a traffic violation?

    1. YES

    1. NO
33. When
34. Where
36. Have you ever filed a lawsuit for bodily injury

    1. YES

    1. NO
38. Do you drive an automobile?

    1. YES

    1. NO
40. Are you related to, or close friend to, any law enforcement officer?

    1. YES

    1. NO
42. Have you served as a juror prior to this term?

    1. YES

    1. NO
44. I certify...

    the above information to be true to the best of my knowledge. I understand that willful misrepresentation of a material fact may be punishable according to Idaho Code §2-208

46. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
48. Electronic Signature
49. Do you wish to donate your jury fees?

    1. YES
    2. NO
Leave This Blank:


51. 1. Receive an email copy of this form.
52. Email address

    This field is not part of the form submission.

53. Submit

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