Jury Duty Notification Form

Jury Duty Notification Form

CPR recognizes jury duty as an important civic responsibility. Use this form to notify your supervisor and Human Resources of a jury duty summons, jury service, or court-related obligation. Please attach a copy of your jury summons and any documentation provided by the court.
Employees are expected to notify CPR as soon as possible upon receiving a summons and keep their supervisor informed of any schedule changes related to jury service. Upon completion of jury duty, additional documentation verifying attendance or service may be requested. Please refer to ADM-HR 115: Jury Duty Policy for additional information regarding eligibility, pay, reporting requirements, and employee responsibilities.
Today's Date

MonthDayYear
Date
Full Legal Name

First NameLast Name
CPR Email Address
example@cprecovery.com
What date is the summons for?

MonthDayYear
Date
Please provide a copy of the Jury Duty Summons.

Cancelof
Supervisor's Full Legal Name

First NameLast Name
Supervisor's CPR Email Address
example@cprecovery.com
Should be Empty: