BOUNDARY COUNTY DISTRICT COURT

DOCTOR'S CERTIFICATE FOR RELEASE FROM JURY SERVICE

I HEREBY CERTIFY THAT ______________________________________________

                                                              (Please print or type name in full)

IS A PATIENT UNDER MY CARE AND THAT SAID PATIENT SUFFERS FROM A PERMANENT OR CHRONIC PHYSICAL CONDITION OR STATE OF HEALTH THAT WOULD MAKE SERVICE AS A JUROR DANGEROUS TO THE PATIENT'S HEALTH OR PERSONALLY EMBARRASSING TO THE PATIENT.

NOTE TO THE PHYSICIAN:  This form is to be used only for circumstances described above. Prospective jurors may request a temporary postponement directly from the Jury Commissioner for temporary circumstances such as pregnancy, broken bones, medical conditions, surgery or recovery. If you have questions, please contact the Jury Commissioner at (208) 267-0924.

______________________________________________________  MD

(Signature)

______________________________________________________

(Please print or type your name)

___________________________________________

(Telephone)

___________________________________________

(Date)

If you are requesting a medical release, please return certificate with signed juror qualification form and retain one copy for your records.