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2. Full Name*
3. Email Address*
5. Address*
7. City*
8. State*
9. Zip Code*
11. Phone Number
13. Request to be Excused*

    Please provide an explanation that includes the details of your request to be excused from jury duty at least three days BEFORE the date on which you are to appear for service. 

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15. 1. Receive an email copy of this form.
16. Email address

    This field is not part of the form submission.

17. Submit

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