Section 21. Enclosed with the juror summons shall be a juror confirmation form. When completed by the juror, this form shall certify whether or not the juror is qualified to serve as a trial or grand juror. The form shall contain the following: a place where the juror may insert the month, day, and year, and an alternate month, day, and year, to which the juror elects to postpone his juror service; a place where the juror may make or acknowledge a declaration that hardship would be imposed upon him if he were required to serve at the court location to which he was summoned; a place where the juror may designate a more convenient jury-trial location within the judicial district; a place where the juror may insert name and address corrections, if applicable; and such other information and instructions as the jury commissioner deems appropriate. The form shall also contain a place for the signature of the juror, and it shall be signed under the penalties of perjury.