*CONFIDENTIAL*
DOMESTIC VIOLENCE PROTECTION ORDER INFORMATION
(TO BE FILLED OUT BY APPLICANT)
Instructions: Please provide all information known to you. Please print information clearly.
APPLICANT DATA
Name: ______________________________________________________________________________________________
(Last) (First) (Middle) (Sex)
Address: ____________________________________________________________________________________________
Mailing Address:
(If different from above)____________________________________________________________________________________________
(Street Address) (Bldg/Apt#) (City) (State) (Zip Code)
Phone Numbers Home: Work: Cell:
Other Name Used: _____________________________________________________________________________________
(Last) (First) (Middle)
Additional Contact Person: _________________Phone: _______________Address:_________________________________
ADVERSE PARTY DATA
Full Name: _____________________________________ Other Name Used: ______________________________________
(Last) (First) (Middle) (Last) (First) (Middle)
Relationship To You: ______________ Date of Birth ____/____/______ and/or Social Security No.:____________________
(MM) (DD) (YYYY)
Last Known Home Address: _____________________________________________________________________________
(Street Address) (Bldg/Apt#) (City) (State) (Zip Code)
Is this address difficult to find? No Yes If yes, please explain:
___________________________________________________________________________________________
Mailing Address:
(If different from above)
_________________________________________________________________________
(Street Address) (Bldg/Apt#) (City) (State) (Zip Code)
Other Likely Address: __________________________________________________________________________________
(Street Address) (Bldg/Apt#) (City) (State) (Zip Code)
Home Phone: _______________________________________Cell Phone: ________________________________________
Occupation: ___________________Employer:______________________ Work Days: _________ Work Hours: _________
Work Phone: _____________Work Address: ________________________________________________________________
(Street Address) (City) (State) (Zip Code)
Hair Color: _____________ Eye Color: __________ Height: _______ Weight: __________ Sex: _______ Race: _________
Scars/Marks/Tattoos (Description and Location): ____________________________________________________________
____________________________________________________________________________________________________
Does the Adverse Party speak English? Yes No If not, what language does he/she speak? ___________________
Vehicle Make: ______________ Model: ____________ Year: ___________ License Plate Number/State: _____________
(Check one)
Are the Applicant and the Adverse Party living together now? Yes No
Are the Applicant and the Adverse Party employed by the same employer? Yes No
Is the Adverse Party likely to react violently when served? Yes No
Is the Adverse Party likely to avoid service? Yes No
Does the Adverse Party have a Carrying Concealed Weapon (CCW) Permit? Yes No
Does the Adverse Party have access to weapons? Yes No
If yes, please describe type and location of weapon(s):
___________________________________________________
___________________________________________________________________________________________
Does the Adverse Party’s history include any violent behavior or crimes? Yes No
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.
Domestic Violence Protection Order Information Revised September 2008
