REQUEST FOR MEDICAL EXCUSE FROM JURY SERVICE
[Pages:1]_______________ COURT COUNTY OF __________ STATE OF NEW MEXICO
REQUEST FOR MEDICAL EXCUSE FROM JURY SERVICE
Some mental and physical problems do not warrant an excuse from service but may warrant a postponement. For any excuse that you provide, please be aware that you may be called to testify before the court about your representations regarding your patient's inability to perform jury service. ALL questions must be answered legibly. If not, this application will be considered incomplete and invalid.
Patient Name:
DOB:
Juror ID Number:
Address:
State:
Zip Code:
Describe any mobility, physical or mental restrictions that make the prospective juror unfit for jury service:
List the specific symptoms that make this person unfit for jury service and state how long these symptoms have occurred:
When will this person be able to serve as a juror?:
Print Name of Physician, Physician Assistant, or RNP:
Business Address: Business Phone: Physician License Number:
State:
Zip Code:
Specialty:
Physician Assistant License Number:
Nurse Practitioner Certificate Number:
I swear or affirm under penalty of perjury under the laws of the State of New Mexico that the contents of this document are true and correct to the best of my knowledge and belief.
Signature of Physician, Physician Assistant, or RNP,
Date:
This document is not a public record and shall not be disclosed to the general public.
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
- affidavit for excuse or deferral from jury duty child care giver excelshe
- jury duty excuse letter
- jury duty excuse letter excelshe
- jury service request to be disqualified postponed or excused california
- request for excuse from jury service
- jury physician certification in support of medical excuse request
- request for medical excuse from jury service
- excusal postponement of jury duty for medical reasons
- court of common pleas general and domestic relations division jury duty
- certification in support of request to be excused from jury service due
Related searches
- free printable medical excuse forms
- medical work from home positions
- printable request for medical records
- online medical jobs from home
- request for medical records letter example
- request my tax transcript from irs
- free printable request for medical records
- medical excuse from jury duty
- remote medical jobs from home
- mn courts jury service questionnaire
- federal jury service summons
- 500 medical form from dss