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Application For A Temporary Order Against Harassment In The Workplace Form. This is a Nevada form and can be use in Clark County.
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Tags: Application For A Temporary Order Against Harassment In The Workplace, Nevada County, Clark
JUSTICE COURT, LAS VEGAS TOWNSHIP
CLARK COUNTY, NEVADA
__________________________________, )
)
Plaintiff
)
(Employer or authorized
)
agent of employer)
)
)
vs.
)
__________________________________, )
Defendant.
)
(NOTE:
The request must be
)
limited to one defendant
)
only.)
)
____________________________________)
IN THE MATTER OF THE
APPLICATION FOR A
TEMPORARY ORDER FOR
PROTECTION AGAINST
HARASSMENT IN THE WORKPLACE
Case No.____________________________
(To be completed by court staff)
AFFIDAVIT
The above named Plaintiff(s), being first duly sworn, deposes and says:
The Defendant named above has committed an act or acts constituting harassment in the
workplace.
NAME OF POLICE DEPARTMENT AND REPORT NUMBER WHERE A COMPLAINT
ABOUT THESE ACTS HAS BEEN FILED (IF APPLICABLE):
____________________________________________________________________________
The relevant information about my workplace is as follows:
BUSINESS NAME:
ADDRESS:
________________________________________________
________________________________________________
________________________________________________
________________________________________________
The relevant information about the defendant is as follows:
NAME:
ADDRESS (if known):
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
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The acts occurred as follows: (Be specific as to the alleged acts of the defendant, the identity
of all relevant parties, all important dates and locations, etc. Also, please make sure that
the information you provide is LEGIBLE.)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
*PLEASE ATTACH ADDITIONAL SHEET(S) IF MORE SPACE IS NEEDED.
Provisions Relating to Notice
(Please check the appropriate box.)
9
The Defendant has been given advance notice about this Application for a
Temporary Order, based on the following:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
9
The Defendant has not been given advance notice about this Application for a
Temporary Order. If this box is checked, you must fill out and submit an
additional form from the court. This form is entitled ASupplemental
Affidavit Relating to Lack of Notice to the Defendant.@
I, therefore, request that a Temporary Order for Protection against Harassment in the Workplace
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be issued against the Defendant so that the Defendant will be enjoined from contacting my
business and/or its employees and/or any person present at the workplace, and so that the
Defendant will be ordered to stay away from my workplace. I also request that the Court prohibit
the Defendant from violating this Order via e-mail, correspondence, telephone,
or agent.
Under the penalty of perjury, I (Applicant) swear or affirm that the above information is true and
that the requested Temporary Order for Protection Against Harassment in the Workplace should
be granted.
Plaintiff=s Signature __________________________________________
PLEASE COMPLETE SECTION 1 OR 2 BELOW:
(1) NOTARY:
PLEASE STAMP BELOW:
Signed and Sworn to or Affirmed
Before Me This
_______ day of ______________, 20_____.
Notary Public______________________________
(2) UNSWORN DECLARATION (Per NRS 53.045):
(a) If executed in this state:
"I declare under penalty of perjury that the foregoing is true and correct."
Executed on
___________________
___________________________________
(Date)
(Signature)
(b) If executed outside this state:
"I declare under penalty of perjury under the law of the State of Nevada that the foregoing
is true and correct."
Executed on
___________________
___________________________________
(Date)
(Signature)
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