STATE OF NORTH CAROLINA County Name And Address Of Petitioner/Employer File No. In The General Court Of Justice District Court Division Name And Address Of Respondent VERSUS TEMPORARY NO-CONTACT ORDER PURSUANT TO THE WORKPLACE VIOLENCE PREVENTION ACT EX PARTE G.S. 95-264 FINDINGS The Court hereby finds that: 1. The Court has jurisdiction over the subject matter. 2. This order is entered ex parte. Immediate and irreparable injury, loss, or damage will result to the petitioner before notice can be served and respondent heard in opposition because (define injury and state why it is irreparable) and it appears by certificate of the petitioner the efforts that have been made to give notice and reasons supporting the petitioner's claim that notice should not be required. that there is good cause to hear the matter ex parte because the harm that is intended to be prevented would likely occur if respondent were given prior notice of the petitioner's efforts to obtain judicial relief. 3. This order is entered after notice has been provided to the respondent. Present at the hearing were: the petitoner, represented by the respondent, represented by 4. The petitioner has suffered unlawful conduct by the respondent in that: . . 5. Other: CONCLUSIONS 1. The respondent committed acts of unlawful conduct against the petitioner. 2. The petitioner has failed to prove grounds for issuance of a temporary no-contact order. AOC-CV-533, New 7/11 © 2011 Administrative Office of the Courts (Over) American LegalNet, Inc. www.FormsWorkFlow.com 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 apporipriate by the court: 7. The terms of this order shall be effective if less than 10 days) for ten (10) days from the date of this order. . until (specify date and time 8. It is ordered that the parties appear at the time and date set out below for a hearing on whether a permanent no-contact order should be entered. Date Of Hearing Time Of Hearing Location Of Hearing AM Date Time PM Name Of District Court Judge Or Designated Magistrate (Type Or Print) Signature Of District Court Judge Or Designated Magistrate AM PM 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. 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 and retained by the police department of the municipality of the employer's workplace. If the employer's workplace is not located in a municipality or in a municipality with no police department, copies shall be issued promptly to and retained by the sheriff and the county police department, if any, of the county in which the employer's workplace is located. AOC-CV-533, Side Two, New 7/11 © 2011 Administrative Office of the Courts American LegalNet, Inc. www.FormsWorkFlow.com