You must have JavaScript enabled to use this form. Date Today's date Business Name Please enter the name of the business Business Address Please enter the address of the business Business City, State, & Zip Please enter the city, state, & zip of the business Email Address Please enter the email address of the person who is issuing this notice Our company, __________________________________________________, can prohibit individuals from entering its property who interfere with its business, shoplift, destroy property, or otherwise behave in a manner that is unacceptable. It has been determined you have engaged in conduct sufficient to necessitate limiting your access to our property. This document constitutes formal notice and warning that you are no longer allowed on this property (listed above) or any area subject to our control. This restriction on entry includes, but is not limited to, all retail locations or subsidiaries of our company/properties including our parking lot. Should you elect to ignore this notice and enter or remain on our property, we will contact law enforcement to respond and request you be charged with Criminal Trespass under Oregon ORS §164.245, 164.255. Trespass Notification Given to: Name Please enter the name of the recipient this notice is issued to Address Please enter the address of the recipient this notice is issued to City, State, & Zip Please enter the city, state, & zip of the recipient this notice is issued to Date of Birth Please select the date of birth of the recipient this notice is issued to Sex Sex Male Female Is the Person an: Is the Person an: Adult Juvenile Anyone 18 years or older is considered an adult Acknowledgement of Receipt I have read and understood this notice or, in the alternative, have had it read to me and understand and acknowledge that as of ______day of _________________________, 20___ I am prohibited from entering this property for a period of _________________________________ and are subject to arrest and being charged with Criminal Trespass if I elect to ignore this warning. Signature of Recipient Signature of the recipient who is receiving this notice Parent Signature Signature of parent only if the recipient is under 18 years old Company Owner / Representative Signature Signature of the person issuing this notice Company Owner / Representative Printed Name Please type the name of the person issuing this notice Boardman Police Department Case Number For office use only Leave this field blank Print
