Plaintiff(s) name/address/phone
Name:   
First Name   Middle Name   Last Name   
Address:   Address   
Phone:   Phone   
E-mail Address:   E-mail Address   

Plaintiff(s) Attorney name/address/phone
Name:   Name   
Address:   Address   
Phone:   Phone   
Law Firm/Bar #:   Law Firm/Bar #   
E-mail Address:   E-mail Address   

Defendant(s) name/address/phone:
Name:
First Name   Middle Name   Last Name      
Address:   Address   
Phone:   Phone   
E-mail Address:   E-mail Address   

Defendant(s) Attorney name/address/phone:
Name:   Name   
Address:   Address   
Phone:   Phone   
Law Firm/Bar #:   Law Firm/Bar #   
E-mail Address:   E-mail Address:   

Date:   Date   
Signature of initiating party or representative:   Signature   

Applicant (print your name),

First Name   Middle Name   Last Name               

Adverse Party (print the name of the person you want protection from).

First Name  Middle Name   Last Name                              

1. Your information ( you are the "Applicant").

Your name:   
First Name          Middle Name   Last Name      

2. Who do you want to be protected from (this person is the "Adverse Party"):

Name:   
First Name         Middle Name    Last Name           

The Adverse Party committed acts of stalking or aggravated stalking against me.
 Definition of stalking, aggravated stalking and harassment:

Stalking: A person commits the crime of stalking when, without lawful authority, that person willfully or maliciously engages in a course of conduct directed towards a victim that would cause a reasonable person under similar circumstances to feel terrorized, frightened, intimidated, harassed or fearful for his or her immediate safety or the immediate safety of a family or household member, and that actually causes the victim to feel terrorized, frightened, intimidated, harassed or fearful for his or her immediate safety or the immediate safety of a family or household member. NRS 200.575(1)

Aggravated Stalking: A person who commits the crime of stalking and in conjunction there with threatens the person with the intent to cause the person to be placed in reasonable fear of death or substantial bodily. NRS 200.575(2)

Harassment: A person commits harassment when: (a) Without lawful authority, the person knowingly threatens: (1) To cause bodily injury in the future to the person threatened or to any other person; (2) To cause physical damage to the property of another person; (3) To subject the person threatened or any other person to physical confinement or restraint; or (4) To do any act which is intended to substantially harm the person threatened or any other person with respect to his or her physical or mental health or safety; and (b) The person by words or conduct places the person receiving the threat in reasonable fear that the threat will be carried out. NRS 200.571

The Adverse Party committed a sexual assault on me.

 Definition of sexual assault: A person commits sexual assault if they subject another person to sexual penetration, or forces another person to make a sexual penetration on himself or herself or another, or on a beast, against the will of the victim or under conditions in which the perpetrator knows or should know that the victim is mentally or physically incapable of resisting or understanding the nature of his or her conduct. NRS 200.366

Protection of Children: The parent or guardian of a child may petition any court of competent jurisdiction on behalf of the child for a temporary or extended order against a person who is 18 years of age or older and who the parent or guardian reasonably believes has committed or is committing a crime involving: (a) Physical or mental injury to the child of a nonaccidental nature; or (b) Sexual abuse or sexual exploitation of the child. NRS 33.400

5. How do you know the person you need protection from (check all that apply)?
We are related by blood or marriage.  Explain Explain      
We are or used to be friends/acquaintances.   
We are neighbors or reside in the same neighborhood   
We are or were co-workers.   
Other: (specify relationship):   specify relationship        

6. Are there any other current or prior court cases that involve you and the Adverse Party in any court?

No 
Yes. If you know, please list the case type, county, state, and case number:   case type, county, state, and case number      

7. Firearms/Guns.
Does the Adverse Party own a gun or have a gun in his/her possession or control?

No    Yes    I don't know      

8. Most Recent Event. Think about the most recent event. These questions ask about the most recent event only.

Approximate date it happened:   Date      
City/State/Location where it happened:   City/State/Location   
Did the other person use or threaten to use a weapon?    No    Yes   

9. Past Event(s).

Think about any other times the person you want protection from threatened or abused you and/or the child/children. The following questions ask about any past events that may have happened.

10. Law enforcement involvement.

Was law enforcement informed?    No    Yes

a. If so, please provide a copy of the police/incident report.
Was anyone arrested?    No    Yes (Who):   Who 
Is the Adverse Party in jail?    No    Yes          

11. Temporary Protections requested (check all that apply).

Do not list any confidential addresses.

The other person will get a copy of this application and will see any addresses you write down.

Prohibited Activities The Adverse Party should not threaten, physically injure, or harass me and/or the minor child, either directly or through someone acting on his/her behalf.   

No Contact or Restricted Contact. The Adverse Party should not contact me and/ or the minor child at all, either in person, by phone/text, by email or through social media.

Current Residence. The Adverse Party should stay away from my current residence.

 Do you and the Adverse Party live together? No    Yes
If yes, whose name is listed on the lease/title?   Name   

Does the Adverse Party know where you live?    No  Yes  
If no, is your address confidential? No  Yes (don't list your address)   
Address: Address   
City, State, Zip: City, State, Zip Code   
County: County      

Do you and the Adverse Party live in the same complex/property/trailer park?

No Should the Adverse Party stay away from the entire complex/property/trailer park?    No    Yes    

Yes. If so, explain the distance and need for protection in that complex/property/trailer park:   Explain     

Personal Belongings.   

a. I need to get my belongings. I want law enforcement to come with me to the Adverse Party's residence so I can pick up my belongings. The address I need to go to is (list street address, apartment number, city, state, zip):   street address, apartment number, city, state, zip   

b. The other party needs to get his/her belongings. Law enforcement should come with the Adverse Party to my residence to pick up his/her belongings.     

Work. The Adverse Party should stay away from workplace.  

Do you and the Adverse Party work at the same place? No    Yes   
Is your work address confidential? No  Yes (do not write details below)

Employer:   Employer   
Address:   Address   
City, State, Zip Code:   City, State, Zip Code   
County:   County   

Employer:   Employer   
Address:   Address   
City, Sate, Zip Code: City, State, Zip Code   
County: County      

School/Daycare.The Adverse Party should stay away from my school and/or the child's school/daycare.

Is the school/daycare address confidential? No    Yes (do not write details below) 

School/Daycare:   School/Daycare   
Address:   Address   
City, State, Zip Code:   City, State, Zip Code   
County:   County   

School/Daycare:   School/Daycare   
Address:   Address   
City, State, Zip Code:   City, State, Zip Code   
County:   County   

Other Places. The Adverse Party should stay away from the following places that I and/or the minor children go to regularly.
 
Location:   Location   
Why?   Why?   
Address:   Address   
City, State, Zip Code:  City, State, Zip Code   
County:    County     

Location:   Location   
Why?   Why?   
Address:   Address   
City, State, Zip Code:   City, State, Zip Code   
County:   County   

13. Other Exhibits. You may attach documents, pictures, or anything else that you would like the judge to look at and consider when reviewing your application. The Adverse Party will receive a copy of all documents/evidence you provide.

Describe what you are attaching:   Description   

14. This document does not contain the personal information of any person as defined by NRS 603A.040.

I declare under penalty of perjury under the law of the State of Nevada that the foregoing is true and correct.

Date:   Date   
Submitted by:   Signature      
Print Name:   Print Name   

Dated:   Date   
Submitted by:   Signature   
Print Name:   Print Name   

Name of Person Being Served

Name:    
First Name   Middle Name   Last Name            

Male    Female   

Last Known Address

Street:   Street   
City:   City   
State:   State   
Zip:   Zip   

Phone(s) w/Area Code
Area Code   Phone Number   

Need Interpreter?    Yes    No   
Language:   Language   

Employer Name
Employer Name   

Employer Address
Street:   Street   
City:   City   
State:   State   
Zip:   Zip   

Work
Hours:   Hours   
Phone:   Phone            

Vehicle License Number:   License number   
Vehicle Make and Model:   Make and Model   
Vehicle Color:   Color   
Vehicle Year:   Year   
Driver's License Number:   Driver's License Number   
State:   State   

Does the restrained person have a disability, brain injury, or impairment requiring special assistance when law enforcement serves the order?
Yes    No
If yes, describe:   Describe      

Location of Weapons:
Vehicle   
On Person
Residence   
Describe in detail:   details      

Plaintiff/Applicant Information

Name:   
First Name      Middle Name   Last Name         

Male    Female   

If your information is not confidential, you must enter your address and phone number(s)

Current Address
Street:   Street   
City:   City   
State:   State   
Zip:   Zip   

Phone(s) w/Area Code
Area Code   Phone Number   

Need Interpreter?    Yes    No  
Language:   Language   

If your information is confidential, you must provide the name, address, and phone number of someone willing to be your "contact".

Contact Name:Name   

Contact Address
Street:   Street   
City:   City   
State:   State   
Zip:   Zip   

Contact Phone:
Area Code   Phone Number   

Your Name (OBO Minor Child):

Name:  
First Name        Middle Name       Last Name   

Male    Female    Other      

Birthdate
(MM)/(DD)/(YY)   

Social Security Number

###-##-####   

Race:   Race   

Address:    Street, Bldg/Apt#, City, State, Zip Code              

Mailing Address (if different):   Street, Bldg/Apt#, City, State, Zip Code   

Home Phone:   Home Phone   
Cell Phone:   Cell Phone   
Work Phone:   Work Phone   

Email Address:   Email Address   
I prefer to be notified of future Court dates by   email    mail   

Adverse Party Name

Name:  
First Name  Middle Name    Last Name           

Male    Female    Other      

Birthdate:
(MM)/(DD)/(YY)         

Social Security Number
Social-Security-Number         

Home Address:Street, Bldg/Apt#, City, State, Zip Code   

Is this address difficult to find?
No    Yes      Explain:   Explanation     

Mailing Address (if different):   Street, Bldg/Apt#, City, State, Zip Code   

Other Likely Address:   Street, Bldg/Apt#, City, State, Zip Code   

Home Phone:Home Phone   
Cell Phone:   Cell Phone   
Work Phone:   Work Phone   

Employer:   Employer   
Position:   Position   
Work Days:   Work Days   
Work Hours:   Work Hours   
Work Address:   Work Address   

Scars/Marks/Tattoos (description and location):   Description   

Vehicle Make:   Vehicle Make   
Model:   Model   
Year:   Year   
License Plate Number/State:   License Plate Number/State   

Do you live with the Adverse Party now?
Yes    No   

Have you ever lived with Adverse Party?
Yes    No      

Does the Adverse Party speak English?
Yes    No   What language does he/she speak?   Language   

Do you work for the same employer?
Yes    No   

Is the Adverse Party likely to act violently when served?
Yes    No   

Is the Adverse Party likely to avoid service?
Yes    No   

Does the Adverse Party have a CCW Permit?
Yes    No   

Does the Adverse Party have access to weapons?
Yes    No   If yes, please describe type and location of weapon(s):
Description   

Does the Adverse Party have a history of violent behavior or crimes?
Yes    No   If yes, explain:   Explanation