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- <br />Namc: Last First Middl <br />,.k � ., <br />DOB: <br />Race Sexx <br />t �i <br />fv <br />fftcs Address: w � City <br />State <br />Zip <br />Ile Phalle` <br />Work Phone: <br />L(nder the authority of Administrative Order No. 58-03-24-F and Dark and Open Space Rule -1 ®0115(3), you are hereby= <br />notified that you are prohibited from (check box): <br />E ntering in or using all City (if Eugene parks, open spaces or facilities. <br />The basis for this Notice of Restriction of Use is that on � � you violated Section 6 1 , 0 of the Park <br />and Open ,Space Rules, and/or Section of the Eug Code, 1971, and /or ORS <br />� . W it 9 wl J <br />(Description of the violation.) <br />To wit, you. <br />-�; <br />This restriction of use its effective beginning on ± , and shall remain in effect until <br />If you enter in or use any City of l to ;ene park, open space or facility during the effective period of this No ice, you may he <br />arrested and charged with criminal trespass in the second degree. <br />Pursuant to Park and Open Space Trek R -1.074 you are entitled to an informal hearing to contest this Notice. A request for an <br />infonnal hearing must be made in writing and filed with the larks & . Open Space Division Director r l "the Division Direct r "l <br />within Ott hours (exclusive of weekends) of"receipt of this Notice at the following address: 182€1 Roosevelt, Blvd., Eugene, <br />97402. <br />The Division Director shall schedule a tune and place for the informal hearing to be conducted, which shall be not more than <br />77 haters (exclusive of weekends) of receipt of the request for hearing. At the informal hearing the Division Director will only <br />consider testimony from yore, City personnel involved in the incident that resulted in this Notice, and other witnesses to the <br />incident, The Division Director may exclude anyone, other than you and those presenting testimony, from the informal haring. <br />This Notice shall remain in effect pending any requested hearing. <br />This Notice of Exclusion was delivered to the person named W the top of this Notice at the date: and time shown above by: <br />r <br />(Sip-nature of person a:wstlin ?delivering, notice) <br />I hereby acknowledge receipt of the above. Notice can the date and time indicated above. <br />(Signature of person being issued the notice) <br />whitc Copy! Public Works Crrern (epy: File Yellow C..'optiy; Reptwt, Copy pink. Copy Recipient Gold Copy Officer Appeal notice. Rev 04 <br />