STATE OF NORTH CAROLINA County Name And Address Of Petitioner File No. In The General Court Of Justice District Court Division VERSUS Name And Address Of Respondent NO-CONTACT ORDER PURSUANT TO THE WORKPLACE VIOLENCE PREVENTION ACT G.S. 95-264, -266 FINDINGS This matter was heard by the undersigned district court judge, the court has jurisdiction over the parties and subject matter, and the respondent has been provided notice of the hearing. The Court hereby finds that: 1. (If this block is checked, skip to the order portion of the order) This order is entered by default for the remedy sought in the complaint because the respondent failed to file an answer appear at this hearing notice of the hearing was given to the respondent and the allegations in the complaint are sufficient to justify a no-contact order for unlawful conduct. the petitioner, represented by the respondent, represented by . . 2. Present at the hearing were: 3. The petitioner's employee has suffered unlawful conduct by the respondent in that: 4. Other: CONCLUSIONS 1. The respondent committed acts of unlawful conduct against an employee of the petitioner. 2. The petitioner has failed to prove grounds for issuance of a no-contact order. ORDER It is ORDERED that: 1. the respondent not visit, assault, molest, or otherwise interfere with the employer or the employer's employee at the employer's workplace, or otherwise interfere with the employer's operations. 2. the respondent cease stalking the employee at the employer's workplace. 3. the respondent cease harassment of the employer or the employer's employee at the employer's workplace. 4. the respondent not abuse or injure the employer, including the employer's property, or the employer's employee at the employer's workplace. 5. the respondent not contact by telephone, written communication, or electronic means the employer or the employer's employee at the petitioner's workplace. 6. Other relief deemed necessary and appropriate by the court: 7. the terms of this order shall be effective until one (1) year from the date of this order. than one year 8. the order is denied and the case is dismissed. Date Name Of District Court Judge (Type Or Print) speci y date and time i ess Time Signature Of District Court Judge NOTICE TO RESPONDENT: A KNOWING VIOLATION OF A CIVIL NO-CONTACT ORDER SHALL BE PUNISHABLE AS CONTEMPT OF COURT WHICH MAY RESULT IN A FINE OR IMPRISONMENT. AOC-CV-534, New 7/11 © 2011 Administrative Office of the Courts (Over) American LegalNet, Inc. www.FormsWorkFlow.com CERTIFICATION I certify this order is a true copy. Date Signature Of Clerk Deputy CSC Assistant CSC Clerk Of Superior Court NOTE TO CLERK: G.S. 95-268 provides: "The clerk of court shall deliver on the same day that a civil no-contact order is issued, a certified copy of that order to the sheriff." The statute also provides that a copy of the order shall be issued promptly to the police department of the municipality of the victim's residence, or the sheriff or county police if the victim does not live within a municipality with a police department. RETURN OF SERVICE I certify that this No-Contact Order Pursuant To The Workplace Violence Prevention Act was received and served as follows: Date Served Time Served Name Of Defendant AM PM By delivering to the respondent named above a copy of this order. By leaving a copy of this order at the dwelling house or usual place of abode of the respondent named above with a person of suitable age and discretion then residing therein. Name And Address Of Person With Whom Copies Left Respondent WAS NOT served for the following reason. Date Received Signature Of Deputy Sheriff Making Return Date Of Return Name Of Sheriff (Type Or Print) County Of Sheriff NOTE TO SHERIFF: G.S. 95-268 provides: "Unless the [defendant] was present in court when the order was issued, the sheriff shall serve the order on the [defendant] and file proof of service in the manner provided for service of process in civil proceedings." AOC-CV-534, Side Two, New 7/11 © 2011 Administrative Office of the Courts American LegalNet, Inc. www.FormsWorkFlow.com