*CONFIDENTIAL* DOMESTIC VIOLENCE PROTECTION ORDER INFORMATION (TO BE FILLED OUT BY APPLICANT) Instructions: Please provide all information known to you. Please print information clearly. APPLICANT DATA Name: ______________________________________________________________________________________________ (Last) (First) (Middle) (Sex) Address: ____________________________________________________________________________________________ Mailing Address: (If different from above)____________________________________________________________________________________________ (Street Address) (Bldg/Apt#) (City) (State) (Zip Code) Phone Numbers Home: (Last) Work: (First) Cell: (Middle) Other Name Used: _____________________________________________________________________________________ Additional Contact Person: _________________Phone: _______________Address:_________________________________ ADVERSE PARTY DATA Full Name: _____________________________________ Other Name Used: ______________________________________ (Last) (First) (Middle) (MM) (DD) (YYYY) (Last) (First) (Middle) Relationship To You: ______________ Date of Birth ____/____/______ and/or Social Security No.:____________________ Last Known Home Address: _____________________________________________________________________________ (Street Address) (Bldg/Apt#) (City) (State) (Zip Code) Is this address difficult to find? No Yes If yes, please explain: ___________________________________________________________________________________________ Mailing Address: (If different from above) _________________________________________________________________________ (Street Address) (Street Address) (Bldg/Apt#) (Bldg/Apt#) (City) (City) (State) (State) (Zip Code) (Zip Code) Other Likely Address: __________________________________________________________________________________ Home Phone: _______________________________________Cell Phone: ________________________________________ Occupation: ___________________Employer:______________________ Work Days: _________ Work Hours: _________ Work Phone: _____________Work Address: ________________________________________________________________ (Street Address) (City) (State) (Zip Code) Hair Color: _____________ Eye Color: __________ Height: _______ Weight: __________ Sex: _______ Race: _________ Scars/Marks/Tattoos (Description and Location): ____________________________________________________________ ____________________________________________________________________________________________________ Does the Adverse Party speak English? Yes No If not, what language does he/she speak? ___________________ Vehicle Make: ______________ Model: ____________ Year: ___________ License Plate Number/State: _____________ (Check one) Are the Applicant and the Adverse Party living together now? Yes No Are the Applicant and the Adverse Party employed by the same employer? Yes No Is the Adverse Party likely to react violently when served? Yes No Is the Adverse Party likely to avoid service? Yes No Does the Adverse Party have a Carrying Concealed Weapon (CCW) Permit? Yes No Does the Adverse Party have access to weapons? Yes No If yes, please describe type and location of weapon(s):___________________________________________________ ___________________________________________________________________________________________ Does the Adverse Party's history include any violent behavior or crimes? Yes No Explain: ____________________________________________________________________________________ Do not write in this space. For court purposes only. Issuing Court ORI: NV ________________ Court Case Number: _________________ Law Enforcement: Do not serve this sheet with documents to be delivered. Domestic Violence Protection Order Information Revised September 2008 American LegalNet, Inc. www.FormsWorkFlow.com