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2. Subject's name*
3. Subject's Date of Birth
   Subject's Date of Birth
5. has been informed they are prohibited permanently from entering or remaining on the property of
7. Business/Property Name*
9. including the building and any alcove and/or adjoined parking lot located at
11. Business Address*
13. Subject was advised that if they enter or remain in this area, it could result in their arrest and prosecution for Criminal Trespass in accordance with RCW 9A.52.080.
15. Notified/served on this date and time*
    Notified/served on this date and time

    Notified/served on this date and time
16. Attach Photograph of Trespasser (Optional)
18. Notification:*

    1. Verbally

    1. Written
20. Name of Employee authorizing Trespass*
22. Business Phone #*
24. 1. I certify that all information provided is true and correct to the best of my knowledge and belief.
Leave This Blank:


26. 1. Receive an email copy of this form.
27. Email address

    This field is not part of the form submission.

28. Submit Submit and Print

* indicates a required field