Any Company No Name Street Anytown USA 08111 SECURITY DEPARTMENT BARRING NOTICE ______________________________________________________________________________ Pursuant to Section XX-XXXX of the XXXXXXXXXXXXXXXXXXXXX Code, you are hereby notified that you are not permitted entry at Any Company, No Name Street, Anytown, USA. In the future, if you return to this establishment and gain entry, even if accompanied or invited by a guest, you may be subjected to criminal prosecution for unauthorized entry. Name: GREG JOHNSON RESIDENCE: #123, 456 78 Avenue Anytown, USA 00000 (609) 555-5555 DESCRIPTION: DOB: MM-DD-YY Age: 22 Sex: Male Ht: 6'02" Wt: 175 Hair: BLOND Eyes: BLUE DISTINGUISHING FEATURES: SNAKE TATOO ON LEFT FOREARM Identification: _____________________________________________________________Id The above-mentioned "BARRING NOTICE" has been read to me by the Security Officer and after reading the "BARRING NOTICE" for myself, I fully understand its meaning. I do hereby voluntarily, without duress, threats, or force sign this statement. _______________________________________________________________________________ ___________________________________ SIGNATURE DATE WITNESSES:_________________________________ _________________________________ ___________________________________ SECURITY OFFICER Incident # 36 0000 Occurrence Date: MM-DD-YY