Application For Extended Order For Protection Against Harassment In The Workplace {B-13}

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Case No. ___________________ Dept. No. ___________________ IN THE JUSTICE COURT OF _____________ TOWNSHIP COUNTY OF __________________, STATE OF NEVADA _____________________________________, ) Employer,) ) ) ) ) vs. ) _____________________________________, ) ) Adverse Party. (NOTE: There can only be one adverse party.) APPLICATION FOR EXTENDED ORDER FOR PROTECTION AGAINST HARASSMENT IN THE WORKPLACE (NRS 33.250) PLEASE TYPE OR PRINT CLEARLY. COMPLETE THE APPLICATION TO THE BEST OF YOUR KNOWLEDGE HARASSMENT IN THE WORKPLACE -- Under NRS 33.240, harassment in the workplace occurs when: 1. A person knowingly threatens to cause or commits an act that causes: (a) Bodily injury to himself or another person; (b) Damage to the property of another person; or (c) Substantial harm to the physical or mental health or safety of a person; 2. The threat is made or the act is committed against an employer, an employee of the employer while the employee performs his duties of employment or a person present at the workplace of the employer; and 3. The threat would cause a reasonable person to fear that the threat will be carried out or the act would cause a reasonable person to feel terrorized, frightened, intimidated or harassed. Applicant states the following facts under penalty of perjury: I am the employer or authorized agent of the employer, and I reasonably believe that the Adverse Party threatens to cause or commits an act of harassment in the workplace. The Temporary Order should be extended for the following reasons: Form B-13 Application for Extended Order for Protection Against Harassment in the Workplace ©2007 Nevada Supreme Court June 30, 2007 Page 1 of 3 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Facts from the original Application filed and/or Temporary Order entered in this cause have been incorporated by reference. Subsequent or additional acts have occurred as follows: NOTE: BE SPECIFIC AS TO WHO THREATENED OR COMMITTED WHAT ACT OR ACTS AND AGAINST WHOM. INDICATE APPROXIMATE DATE(S) AND LOCATION(S). ALSO LIST SPECIFIC EMPLOYEE(S)/PERSON(S) PRESENT AT THE WORKPLACE WHO ARE THE FOCUS OF THE HARASSMENT OR WHOM THE ADVERSE PARTY SHOULD BE DIRECTED NOT TO CONTACT. THE FACTS YOU STATE HERE MUST PROVIDE THE BASIS FOR GRANTING AN EXTENDED ORDER FOR PROTECTION AGAINST HARASSMENT IN THE WORKPLACE. THIS FORM IS A PUBLIC RECORD ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ NOTE: PLEASE DO NOT WRITE ON THE BACKS OF ANY PAGES; CHECK BOX IF YOU ARE USING ADDITIONAL PAGES. Check if you use a continuation page (to be incorporated by reference) Form B-13 Application for Extended Order for Protection Against Harassment in the Workplace ©2007 Nevada Supreme Court June 30, 2007 Page 2 of 3 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 RELIEF REQUESTED THEREFORE, I REQUEST that an Extended Order for Protection Against Harassment in the Workplace be issued against the Adverse Party so that the Adverse Party will be enjoined from contacting, intimidating, threatening, or otherwise interfering with the employer's business and/or its employees and/or any person present at the workplace, and that the Adverse Party will be ordered to stay away from the employer's workplace. I also request that the Court prohibit the Adverse Party from violating this Order via electronic mail (e-mail), facsimile (fax), correspondence, telephone, or through another person. I FURTHER REQUEST the following other conditions: ________________________ __________________________________________________________________________________ _____________________________________________________________________________ DECLARATION (NRS 53.045) I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAW OF THE STATE OF NEVADA THAT: (1) I AM THE APPLICANT (EMPLOYER OR AUTHORIZED AGENT) HEREIN, (2) I HAVE READ THE STATEMENTS CONTAINED HEREIN OR HAVE HAD THEM READ TO ME, (3) I BELIEVE THESE STATEMENTS TO BE TRUE, AND (4) THE REQUESTED ORDER IS NEEDED. _________________________ DATE ___________________________________ APPLICANT'S SIGNATURE ___________________________________ PRINT NAME Form B-13 Application for Extended Order for Protection Against Harassment in the Workplace ©2007 Nevada Supreme Court June 30, 2007 Page 3 of 3