*CONFIDENTIAL* HARASSMENT IN THE WORKPLACE PROTECTION ORDER INFORMATION (TO BE FILLED OUT BY EMPLOYER/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. EMPLOYER/APPLICANT DATA Business Name: ________________________________ AKA (if applicable): ____________________________________ Business Contact Person (Employer): __________________________________________________________________ Nature of Business: _______________________________________________________________________________ Business Address: _______________________________________________________________________________ Business Phone: ______________________________ Business Fax Number: ____________________________ Business E-mail: _______________________________________________________________________________ Authorized Agent for Employer:_________________________________________________________________________ Authorized Agent’s Address: _________________________________________________________________________ Authorized Agent’s Telephone Number: ___________________________ Fax Number: ____________________ This business is a: Sole Proprietorship Partnership Corporation Other ___________________________ (Please circle one) Does this business have a prior relationship with the Adverse Party? (For example, is the Adverse Party a former employee/customer/neighboring business owner, etc.?) If yes, please describe the relationship: _____________________ ___________________________________________________________________________________________________ ADVERSE PARTY DATA Adverse Party’s Full Name: ____________________________________________________________________________ Other Name Used by Adverse Party: ______________________________________________________________________ Last Known Home Address: ___________________________________________________________________________ (Street Address) ͕ ͕ (Bldg/Apt #) (City) (State) (Zip Code) Yes If yes, please explain ______________________________ ___________________________________________________________________________________________ Is this address difficult to find? No Mailing Address: (If different from above)________________________________________________________________________________________ (Street Address) (Bldg/Apt #) (City) (Street Address) (Bldg/Apt #) (City) (State) (Zip Code) Other Likely Address: (State) (Zip Code) Home Phone: ________________________ Cell Phone: _________________________ Date of Birth: ______________ Occupation: Employer: Work Days: __________ Work Hours: _______ Work Phone: ____________ Work Address: Hair Color: Eye Color: Height: Weight: Sex: M ____ F ____ Race: ________ Scars/Marks/Tattoos (Description and Location): Does the Adverse Party speak English? If not, what language? (Yes or No) Vehicle Make: ________ Model: ________ Year: ________License Plate Number/State: ___________________________ Does the Adverse Party's history include (please circle): assaults, assaults w/weapon, batteries, 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. *CONFIDENTIAL* Form B-5 Confidential Harassment in the Workplace Protection Order Information ©2007 Nevada Supreme Court June 30, 2007