*CONFIDENTIAL* STALKING AND HARASSMENT PROTECTION ORDER INFORMATION (TO BE FILLED OUT BY APPLICANT) Instructions: Please provide all information known to you and print legibly. All requested information is helpful for service, even if the information is only partially known. Please note that if you do not provide an address for the Adverse Party, or if the sheriff/constable cannot effectuate service at the address you give, Applicant has the ultimate responsibility for having the Adverse Party served by private process server or other means. APPLICANT DATA Name: _____________________________________________________ ________________________________________________________________________ (Last) (First) (Middle) Address Mailing Address: (If different from above)________________________________________________________________________________________ (Street Address) Phone: Home: (Bldg/Apt #) (City) (State) Work: (Zip Code) Cell: Other Name Used: __________________________________________________________________________________ (Last) (First) (Middle) Additional Contact Person: ________________________ Phone: ____________ Address: _________________________ ADVERSE PARTY DATA Other Name Used: Full Name: (Last) (First) Relationship To You (if any): (Middle) Date of Birth (Last) / / (First) (Middle) and/or Social Security No.: (M) (D) (Y) Last Known Home Address: Is this address difficult to find? ͕ (Street Address) No ͕ (Bldg/Apt #) (City) (State) (Zip Code) Yes If yes, please explain ______________________________ __________________________________________________________________________________________ Mailing Address: (If different from above)________________________________________________________________________________________ (Street Address) (Bldg/Apt #) (City) (State) (Zip Code) (Street Address) (Bldg/Apt #) (City) (State) (Zip Code) Other Likely Address: Home Phone: ______________________________________________ Cell Phone: ______________________________ Occupation: Employer: Work Days: __________ Work Hours: _______ Work Phone: ____________ Work Address: (Street Address) Hair Color: Eye Color: Height: Scars/Marks/Tattoos (Description and Location): (City) Weight: (State) Sex (Zip Code) Race: __________________________________________________________________________________________ Does the Adverse Party speak English? If not, what language? (Yes or No) Vehicle Make: ________ Model: ________ Year: ________License Plate Number/State: ___________________________ (Circle one) Are the Applicant and the Adverse Party living together now? Are the Applicant and the Adverse Party employed by the same employer? Is the Adverse Party likely to react violently when served? Is the Adverse Party likely to avoid service? Does the Adverse Party have a Carrying Concealed Weapon (CCW) Permit? Does the Adverse Party have access to weapons? If yes, please describe type and location of weapon(s): Yes or No Yes or No Yes or No Yes or No Yes or No Yes or No Does the Adverse Party's history include (please circle): assault, assaults w/weapon, battery, mental health problems, drug/alcohol abuse, outstanding/prior arrest warrants, safety issues? 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. Form A-5 Confidential Stalking and Harassment Protection Order Information Court ©2007 Nevada Supreme June 30, 2007 *CONFIDENTIAL* Form A-5 Confidential Stalking and Harassment Protection Order Information Court ©2007 Nevada Supreme June 30, 2007