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k C- <br />(5 <br />;4 <br />iddle <br />Name: s, V M <br />D OB: 41 <br />Race/Sex <br />L T <br />V <br />Res. Address; City <br />State <br />Zip <br />Res. Phone: <br />Work Phone: <br />Under the authority of Administrative Order No. 58-03-24-F and Park and Open Space Rule R-1.005(3), you are hereby <br />notified that you arre prohihited from (check box): <br />Entering in or using all City of Eugene parks, open spaces or facilities. <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 />info al hearing must be made in writing and filed with the Parks & Open Space Division Director ("the 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 (exclusive of weekends) of receipt of the request for hearing. At the informal hearing the Division Director will 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 an) 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 />(Signature of person issuiril <br />I hereby acknowledge receipt of the above Notice on the date and time indicated above. <br />--Y- <br />(Signature of person being issued the notice) <br />White Copy: Public Works Green Copy'. File, Yellow Copy: Report Copy Pink Copy: Recipient Gold Copy: Of Appeai nuace Rev. C4,03 <br />