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I" <br />NR-: Last First Middle <br />DOB: <br />Race/S V <br />4 <br />Res. Address: City <br />-19 PK <br />State <br />Zip <br />I <br />Res, Phone <br />Work Phone: <br />I IIIII InIIII! alignarl I III Irr IIIII-111 r0l 11 f I <br />Entering in or using all City of Eugene parks, open spaces or facilities. <br />The basis for this Notice of Restriction of Use is that on you violated Section of the Park <br />and Open Space Rules, and/or Section of the Eugene Code, 1971, and/or ORS ---. To wit, you: "krc <br />- 7k 7 <br />le-f <br />(Description of the violation.) <br />This restriction of use is effective beginning on and shall remain in effect until <br />If you enter in or use any City of Eugene park, open space or facility during the effective period of this Notice, you may be <br />arrested and charged with criminal trespass in the second degree. <br />Pursuant to Park and Open Space Rule R-1 .074 you are entitled to an informal hearing to contest this Notice. A request for an <br />informal hearing must be made in writing and filed with the Parks & Open Space Division Director ( Division Director") <br />within 48 hours (exclusive of weekends) of receipt of this Notice at the following address: 1820 Roosevelt, Blvd., Eugene, OR <br />97402. <br />The Division Director shall schedule a time and place for the informal hearing to be conducted. which shall be not more than <br />72 hours (CUIUSIVC (if weekend%) of receipt ofthe request for hearing. At the informal hearing the Division Director °w ill only <br />consider testimony from you, 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 hearing. <br />This Notice shall remain in effect pending any requested hearing. <br />This Notice of Exclusion was delivered to the person named at the top of this Notice at the date and time shown above by: <br />C 3 ij <br />(Signature o4erson issuing/defivcring notice) <br />I hereby acknowledge receipt of the above Notice on the date and time indicated above. <br />(Signature ot'person being issued the notice) <br />White Copy Public Works Green Copyi File Yellow Copy: Report Copy Pink Copy: Recipient Gold Copy: Officer Appeal notice Rcv% [W03 <br />